Loading...
HomeMy WebLinkAboutMiscellaneous - 148 MAIN STREET 4/30/2018 (9) ���,� � �� � 1 l a Date...,L./* A? R'r#, TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING gsgCHU This certifies that ........ has permission to perform .... K. . ........................................................... ............................. L wiringin the building of..................................... ...................................................................... a t ...........57...........................7j/..................North Andover,Mass. Fee.... Lic.No. el , 01 . .................. Vf ...... ,VKECTfUCAL SPECTOP .. Check# Commonwealth of Massachusetts Official Use Only � T Department of Fire Services Permit No, 2. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 11/10/14 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 148 Main Street Unit A411 Owner or Tenant Jackie Ludgin Telephone No. Owner's Address 148 Main Street Unit A411 Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building Condominium Utility Authorization 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 Proposed Electrical Work: Kitchen Remodel, Panel Change, Replace All Receptacles&Switches Completion o the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires 6 No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 3 Swimming Pool Above ❑ In- 1:1o.o Emergency Lighting rnd. rnd. BafteEy Units No.of Receptacle Outlets 26 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 30 No.of Gas Burners o.of Detection and Initiatin Devices No.of Ranges 1 No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers 1 Heat Pump I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers 1 Space/Area Heating KW Local❑ Municipal M Other Connection No.of Dryers Heating Appliances KW SecuritySystems:* No.of Devices or Equivalent No.o Water KW No.of No.of Data Wiring: Heaters 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. Estimated Value of Electrical Work: $5,225.00 (When required by municipal policy.) Work to Start: 11/10/14 Inspections to be requested in accordance with NEC Rule 10,and upon completion. { INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless i the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Steven M Parker Electric LLC LIC.NO.:21502-A Licensee: Steven M Parker Signature LIC.NO.: 12903-B (If applicable,enter "exempt"in the license number line) Bus.Tel.No.-1-978-360-9592 Address: 633 Riverside Avenue Unit 8 Haverhill,MA.01830 Alt.Tel.No.: 1-978-918-1004 *Security System Contractor License required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE:$ r .�,L C ...-.� L� 1 i � � �i�� // �© The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Invesdgations k17 I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):STEVEN M.PARKER ELECTRIC Address:633 RIVERSIDE AVE APT 8 City/State/Zip:HAVERHILL, MA. Phone#:978-360-9592 Are you an employer?Check the appropriate box: Type of project(required): 1.El am a employer with 4. E] I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑✓ 1 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' Building addition [No workers comp.insurance comp.insurance. t ❑ g required.] 5. ❑ We are a corporation and its 10.71 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] 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. r 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 insurance coverage verification. I do hereb cern under the ains a e hie ' es o u that the in ormation provided above is true and correct !Si ature. Date 11/10/14 Phone#:978-360-9592 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#•