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HomeMy WebLinkAboutMiscellaneous - 1610 Osgood Street iv io ossooa 577— BUILDING rBUtLDING FILE Date.... .. ..(........ wt f �aORTF�1 �p TOWN OF NORTH ANDOVER F PERMIT FOR WIRING SACHUS� This certifies that ....... 1 �sG /............ ............. has permission to perform ............. �.r...v ......................................... �. wiring in the building of.(-(14Q7.. ®8 ... i'L at.......t../ ........ '........................ .North Andover,Mass. Lic.No.. ......... . .!!Fee C.2:.,5 .��.. .- ....... � ```1...... IV ELECTRICAL INsncr SR Check # , � � ,v/ r . 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepfd by ar�lnspector of Wires appointed pursuant to M. G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporatie-- stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time ofongoing construction activity,and may be.deemed-by.the Jnspector_ofWires abandoned-and.invalidifhe—_. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entitystated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. Rule 8—Permit/Date Closed: **Not e:Reapply for new per ❑Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Date Issued: 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: 9/23/09 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) 1610 Osgood St/Suite#3 Map: Lot: Owner or Tenant Cabot Woodworking/Building#34 Telephone No. Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Woodworking Shop Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps Volts Overhead X Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wiring of woodworking Shop Completion ofthefollowing table may be 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- El N—o.of Emergency Lighting rnd. grnd. Battery Units a 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 No.of Waste Disposers Heat Pump Number J.Tons KW No.of Self-Contained Totals: I 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 Kms, 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: Furnish and install new 2"PVC Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $ 15,100 (When required by municipal policy.) Work to Start: 9/21/09 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 licen- see 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 ❑ OTHER ❑ (Specify:) 1 certify,under thepains andpenalties ofperjury,that the information on l is application is true and complete. FIRM NAME: Andover Electric Services, Inc d/` / /F LIC.NO.: 14302 Licensee: Robert J. Branca Signature f / LIC.NO.: *Per M.G.L. c. 147,s. 57-61,security work requires Department ofP& •c Safety"S"License: LIC.NO.: S: (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 978-475-4995 Address: 19 Dale St, Andover, MA Zip: 01810 Alt.Tel.No.: 978-423-8350 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below,I hereby waive this requirement. I am the(check one)❑owner [:]owner's agent. Permit Fee: $125 Owner/Agent Signature Phone: Date.... `. ..r..:.��.?.......... f NORTI{� "�o� TOWN OF NORTH ANDOVER % PERMIT FOR WIRING SSACXUS� This certifies that ...... L C'T/Zr.��6... has permission to perform .....RFM ova ............................................................ 1....,..... wiring in the building of.. Z2 7 � —2...... at ........ . /�' �b.G..� .3�.............. .North Andover,Mass. Fee Z Sri^... Lic.No 13 eT?l A.......... . r .w.0 . ....... ... .!.... ELECTRICAL INSPECTOR Check # G � 8650 Y. This certificate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies. 4 Certificate of Insurance BM0068 Tlris certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is not an insurance policy and does not amend,extend,or alter the coverage afforded by the policies listed below. This is to certify that(Name and address of insured) Electrical Dynamics Inc EDI Network Systems,Inc, j „�� 72b Concord St L rq North Reading,MA 01864-2607 eaarx is,at the issue date of this certificate,insured by the Company under the policy(ies)listed below. The insurance afforded isnot altered by any requirement.term or by the listed policy(ies)is subject to all their terms,exclusions and conditions and condition of env contractor other document with respect to which this certificate maybe issued. Expiration Type Ef./Ex .Date(s) Policy Number(s) Limits of Liability 11 Continuous* 11/01/2007/11/01/2008 WC7-111-259257-017 Coverage afforded under WC law of Employers Liability Extended the following states: Bodily Injury By Accident X Policy Term CT,MA,ME,NH,NJ,NY,PA $500,000 Each Accident Bodily Injury By Disease $500,000 Policy Limit Workers Compensation Bodily Injury By Disease $500,000 Each Person 11/01/2007/11/01/2008 TB2-111-259257-027. General Aggregate-Other than Prod/Completed Operations General Liability $2,000,000 Products/Completed Operations Aggregate Claims Made $2.000,000 Occurrence Bodily Injury and Property Damage Liability Per $1,000,000 Occurrence Retro Date Personal and Advertising Injury Advertising J Y Per Person! $1.000,000 Or ani7ation Other Liability Other Liability 11/01/2007/11/01/2008 AS5-111-259257-047 Each Accident-Single Limit-B.I.and P.D.Combined Automobile Liability $1,000,000 A Owned Each Person % Non-Owned Each Accident or Occurrence X Hired Each Accident or Occurrence Umbrella Excess 11/01/2007/11/01/2008 TH2-611-259257-037 I10,000,000Aggregate Job Number:Permit Purposes Only C 0 M M E N T S Notice of cancellation:(not applicable unless a number of days is entered below). Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above policies until at least 30 days notice of such cancellation has been mailed to: Office: DANVERS,MA Phone: 978-774-0300 r. t Lt+atT Certificate Holder: MARIA ABRANTES City / Town Of Authorized Representative C/O Electrical Dynamics and EDI Network Systems Inc. 72B Concord Street l North Reading, MA 01864 Date Issued: 10/31/2007 Prepared By: DI< l I The Commonwealth of Massachusetts Department of I ndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 a s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers Applicant .Information Please .Print LeviblN, Name (Business/Organization/Individual): Electrical Dynamics, Inc. & EDI Network Systems, Inc. Address: 72 B Concord Street City/State/Zip: North Reading, MA 01864 Phone#: (978) 664-1050 Are you an employer?Check the appropriate box: Type of project (required): 1.7 I am a employer with 150 4. ❑ 1 am a general contractor and I employees(full and/or part.time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- Iisted 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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.7 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' comp. insurance required:] 13.❑ Other *Any applicant that checks box 0 must also fill out the section below showing their workers'compensation policv information. t Homeowners who submit(his affidavit indicating they are doing all work,and then hire outside contractors must submit z new affidavit indicating such lContractors 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 the policy and job site information. Insurance Company Name: Liberty Mutual Policy#or Self-ins. Lic.#: WC7-111-259257-017 . 11/01/08 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 DLA for insurance coverage verification. I do hereby ce unde a pains and penalties of perjury that the information provided above is true and correct. Sisnature: Date: Phone#: 8) - 50 Official rise only. Do not write in this area, to be completed by city or town official City or Town: Permit/lLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of Massachusetts official Use only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ [Rev. 11/99] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD 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: 09 City or Town of: AV\ ,jav_01(' 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) f6 G�cyc'0n Owner or Tenant r2 z t 5 Telephone No. Owner's Address ac-�C Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building 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: -�n 2f�;Ze at1 � 1, qK0 V '�e C k\&-' (4: C) Completion of the followin table may be waived by the Ins ector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)FansNo.of Total Transformers KVA No. of Lighting Outlets No.of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ED * o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No..of Zones No. of Switches No.of Gas Burners No. If Detection Dean es No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices No.of Waste Disposers Heat Pump umber Tons � K No.,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 ea 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. 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 ❑ OTHER ❑ (Specify:.) Estimated Value of Electrical Work: •G Cj (When required by municipal:policy.) (Expiration Date) Work to Start: L - Inspecti ns to be requested in acco ance with MEC Rule 10,and upon completion. I cert,under the pains an penalties of perjury,thatthe inform non app cation is true and complete FIRM NAME:ELEC�RICAL DYNAMICS,INC. LIC. NO.: A13881 Licensee:GARY R.LETOURNEAU Signature LIC.NO.:A13881 (Ifapplicable,enter "exempt"'in the license number line.) Bus.Tel. No.:-979-664-1 050 Address: 72B Concord Street North Reading,MA 01864 Alt.Tel. 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 agent. Owner/Agent Signature Telephone No. FPER�T FEE. $ Date....3.......................... NORTp °ft"'° '•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING 41 CHU This certifies that ............ r.'...5.' ..- has permission to perform .......... ......C!?..........................................................� wiring in the building of....... wa© d'p "/�!� .... ..... .... . ........... at. ,�p ............ .. i.............. ....North Andover,Mass. ' Fee...... ..ab Lic.NoJ .??e4...... . .. ELEC TRICALINSPECT ;P Check # 365 803 338.24 ARTICLE 340-UNDERGROUND FEEDER 2-00 S CObAr nce,LU e.Mergroun""d e c en ante caa'le : s . mno; 'e use un .ere i 1 Orn"1"r�ri"or"""w%ti" "` (2) o atap+e� � MRSMLI om a un an' �`fmuna „dnn an enc_ - (3) �s'Baena,.ca est i a g TKI cone uct abbe i i,�„� ru ezaegroun >an anst �astme �r Mored "wgo' 6f�i'cle��Ib Lf 4b:' Commonwealth of Massachusetts Official Use only F• �� ��� ' Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSTOccupancy and Fee Checked [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 WINK OR TYPE ALL INFORMATION) Date: _ /,_Q q 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) 1610 Owner or Tenant p) NAl,g(!CC, i0oo wo/�/Ci.J Telephone No. Owner's Address /(/ 0 a S C•.oo A <—i' Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 2�)Yjs,-7,.j l Utility Authorization No. Existing Service 6,—fL Amps16�)/ 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: Completion o the ollowin table maybe waived by the Inspector of 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- El .o Emergency Lighting Lyrnd. rnd. Baotte Units j No.of Receptacle Outlets No.of OR Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and TotaInitiatin Devices No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons Im No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* N No.of Water No.of No.of o.of Devices or Equivalent Heaters KW Signs Ballasts DatN of DWirinevices or Equivalent No.Hydromassage Bathtubs No.of Motors Tot Telecommunications irmg: Total'HP No.of Devices or Equivalent OTHER: /Z Eer7..1 K � G Attach additional detail if desired,oras required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 lice �. licensee provides es 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 L2"'BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: y/—_S LIC.NO.: Licensee: Y�f y�� ���a�� Signature LIC.NO.: (If applicable, enter "exempt"in the license number line) Bus.Tel.No.: Address: 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE.$ 91( The Commonwealth of Massachusetts Department of Industrial Accidents 4jf1ce of Investigations 600 Washington Street X i J Boston, MA 02111 www.nxass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Levibly Name(Business/Organization/individual): Address: City/State/Zip: Phone#: . Are Y9u an employer?Check the appropriate box: Type of project(required): L I 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.❑ I am asole proprietor or partner- listed on the attached sheet.i E] Remodeling ship and have no employees These sub-contractors have 8. Demolition working for mein any capacity, workers' comp.insurance. g. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.7 Electrical repairs or additions right of exemption per MGL I I.. Plumbing. 3.❑ I am s homeowner doing all work g pt p ❑ g repairs or additions myself.[No-workers'comp. c. 152, §1(4),and we have no 121-1 Roof repairs insurance required.)t employees. [Noworkers 13.[]Other comp,insurance required.] *Any applicant that checks bo>lr#l 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. j 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and&air workers'comp.policy information. I am an employer that is providing workers'compensation insurance for m1'employees: Below isthe policy and job site information. Insurance Company Name: / Policy#or Self-ins.Lic.4: On/ F',f L Expiration Date: Job Site Address: City/State0p: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration ratton date). Failure to secure coverage as required under Section 25A of MGL e. 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 DTA for insurance coverage verification. I do hereby certijy under the pains and penalties o perjury that the information provided above is true and correct Signature: Date: Phone#: 33 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#: z, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or focal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not'the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the nuinber iisted below. Self.-insured companies should enter their t, self-insurance license number on the appropriate line. City or Town Officials r Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license of permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA€12111 Tel.# 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax#617-727-774 www.mass.gov/dia ��y� �' �����/;' Date.................................. N°RTF♦ �"' °t ��`°;•'"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACM15� Thiscertifies that ............................................................ .............................. has permission to perform ............................................................................... wiringin the building of................................................................................... at............................................................................... .North Andover,Mass. Fee..................... Lic.No.............. ............................................................... ELECTRICAL INSPECTOR Check # Commonwealth ofMassachusetts Utncial UseUnly Department of Fire Services Permit No. -3 Occupancy and Fee Checked l ��✓ I BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 (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: A10V "7 9004 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) /6/0 (),S h o i l-) S"'t� Owner or Tenant •7"j)N)� /}i�4 iy Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building 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 t Location and Nature of Proposed Electrical Work: 'l �'F/i ➢�`� �� �� `�,1�] 17�- Completion of the following table may be waived by the Inspector of 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- El o.o Emergency Lighting rnd. rnd. Battery 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 No.of Waste Disposers Heat Pump Number Tons KW No.o Self-Contained Totals: . Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mun'cipal ❑ 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 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: 6—D 0 (When required by municipal policy.) Work to Start: 1(10V 2,Ao,�4 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 in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE QC BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Z22 24 Licensee: S ,�/. � Signature LIC. NO.: 774,[f (If applicable, enter "exem t"in the license numbg r line.) Bus.Tel. No.�� Address: 9T I-A Alt.Tel. No.: *Security S em Contractor License required for this work; if applicable,enter the license mber 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. 1 am the(check one)❑ owner ❑ owner's agent. Owner/Agent .PERMIT FEE: Signature Telephone No. i ��� �'