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Home My WebLink AboutMiscellaneous - 14-16 Fernview Drive w �► 02 Date..... ..z.7....- .1�/. f HORTl1 1 3?;•tom`` O� TOWN OF NORTH ANDOVER 0 ° A PERMIT FOR WIRING M c � ,SSACMU1-7 SE� This certifies that .... fr 4.........�v... .. ............................................. has permission to perform ... . ..'r.:.4...... 5(.. ........... r.,r. ..., wiring in the building"of c ./..J`u...:r....... ...................... 6...... .: ~.'' `c�-� .......... ,North Andover, ass. at./. ... ✓,� Fee7..U..'......... Lic.No/ 3Y . ////.r.. .�.. .. ...... ............... v� ELECTRfCAL NSPECTOR Check # Z� Official use only Commonwealth of Massachusetts ° Permit No. 3 7-2,- Department Z/Department of Fire Services Occupancy and Fee Checked — <..- BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12. (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / City or Town of A/ To the Inspe tor-of Wires: By this application the undersigned gives notice of is or her intention to perform the electrical work described below. t ^ Location(Street&Number) - N Owner or Tenant A-r sem' As'SaG Telephone No.gZr b�ff=4�$Y-1 O Owner's Address \ Is this permit in conjunction wito a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building `S_ % vT� -�j;� l Utility Ant orization No. Existing Service Amps / Volts Overhead Undgrd❑ No.of Meters - New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Propos d ectri al Wor �S r ) • t t Com letion of the fo6owing table maybe waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.ot Emergency ig ing rnd. grnd. Batte Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection an Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Sec my Systems: N . of Water NDevices or Equivalent No.o No.o Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ rOOTTHER ❑ (Specify:) 9/30/2011 Estimated Value of El trica Work: ` (When required by municipal policy.) (Expiration Date) Work to Start: / Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains and penalties of perjury,that the information this a ca c i is true and complete. FIRM NAME: HELCO ELECTRIC INC. LIC.NO.:A6238 Licensee: Signature LIC.NO.: Ale)' e) (If applicable, enter "exempt"in the'license licensumber line.) Bus.Tel.No. 978-532-7500 Address: ZERO CENTENNIAL DRIVE, PEABODY, MA 01960 Alt. Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ha*-Ke liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent f_ Signature Telephone No. PERMIT FEE: $ ~` Print.Form The Commonwealth of Massachusetts .. .......... * Department of Industrial Accidents tOffice of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 ra www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Helco Electric,Inc. Address:Zero Centennial Drive City/State/Zip:Peabody, MA 01960 Phone#:978-532-7500 Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with 40 4. ❑ I am a general contractor and I employees nd/orpsrt-time). * have hired the sub-contractors 6. E]New construction full 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity, employees and have workers' insurance.$ 9. ❑ Building addition comp.[No workers' comp.insurance required.] 5. ❑ We are a corporation and its 10.2 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Independence Casualty Insurance Co. Policy#or Self-ins.Lic.#:WC100060101 Expiration Date:9-30-2011 Job Site Address: City/State/Zip: X67 Y e2/� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for in ance coverage verifi ' n. I do hereby cern under the ains and"p"enaltieAf"pedyly that the information provided aboveis ue andorrect. Si ature: 1&�, G� _ Date: Phone#:978-532-7500 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: g y'-27 t t J . l