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Home My WebLink AboutMiscellaneous - 148 MAIN STREET 4/30/2018 (22) `� �, �. �� W �_._- -- -�"; 0262 Date...I....:l:-..../�....... NOR71� °f4"`°;•1"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 'SACMUSE This certifies that has permission to perform............ ..1.. 1!(/............................... wiring in the building of......1. �K�.�.�/......................................... at.... .....1�. .`L .... ........................................ .. .North Andover,Mass. Fee.:5 1. ........... Lic.No.oz��.7.'��° ....... .,.t �IiN�S rte'..,....... ELecR Check .4. i � _ Official Use Only Commonwealth of Massachusetts Permit No. � . Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 / (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 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) ft Q17') cS-� oQce Owner or Tenant ,o rn y1bas Telephone No. Owner's Address G>he Is this permit in conjunction with a building permit? Yes: No ❑ (Check Appropriate Box) Purpose of Building 9•�'�Z Gy, Utility Authorization No. Existing Service Amps Id.0 / [v 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: e (O1tM( t-r-C cis-ed en-1' i h Com letion of the following Ale may be waived by the Inspector o Wires. No.of Recessed Luminaires No,of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump I.NPT4erlTons KWNo.of Self-Contained Totals: ...........""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* ., No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns 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: (When required by municipal policy.) Work to Start: 9 - 9- U Inspections to be requested in accordance with MEC Rule 10,and upon completion. 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 je ,alliesofperyy ce,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEBOND ElOTHER�❑ ,(Specify:) I certify,under the pains and ,that the information on this application is true and complete. FIRM NAME: � LIC.NO.: o710 -,3-,4 Licensee: Signature LIC.NO.: `'wo-c- _ (If applicable, enter "exempt"in the icense number line.) r ' Bus.Tel.No. 7 1 V 7�s Address: JrY Gylej 'S (' S? AA Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety 'S"License: Lic.No. 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 Owner/Agent Signature Telephone No. PERMIT FEE: $ r' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information nn Please Print Legibly Name (Business/Organization/Individual): R Address: � t City/State/Zip: W.,r�S /�iri' ®� ne Are an employer?Check the appropriate box: Type of project(required): 1. am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10 lectrical repairs or additions I 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is tile policy and job site information. /J f Insurance Company Name: ! ot,41''`- /,� Policy#or Self-ins.Lic.#: Vo�,S — Expiration Date: y Job Site Address: /J 14M City/State/Zip: A4 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 hereby certif the * s�a�nf-penalties of perjury that the information provided above is true and correct. Si nature: li �f`'^^"�► �J Date: Phone#: �7� Sb9 7 77 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#: J' s r