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Home My WebLink AboutMiscellaneous - 162 Kingston r' 112 BUILDING FILE Date..�..�1... ................... NORTH TOWN OF.NORTH ANDOVER PERMIT FOR WIRING • i �: 8s'�CMUS� Thiscertifies that .......................... .. U........................................................................................ has permission to perform ,(P��. .�..... � "y�' wiring in the building of...... � . ...rC�.......................................................................... at 1 C� �. '`� ' North Andover M s. ................. 5 .. ................................ Fee. S`? Lic.No'.(D.4.. l� " ELECTRICAL SP CTO ~ Check# 3� Commonwealth of Massachusetts Official se Only ' 1 Department of Fire Services Permit No. 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 CodeEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: WTI I l!3 City or Town of: Noritn NAdOl e.1r 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) I [rrja- F-N'�,9 5+ Owner or Tenant I ab;o i-('eco Telephone No. -716 - 3A-V 3y Owner's Address 1(, - k,\ �Soz, $�- Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building Dv461 lvI4 1 kSae,4- &l Utility Authorization No. T Existing Service 10 0 Amps iii/a d Volts Overheadff 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: COI JO UA,+ 0 Completion o the followingtable 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- Elo.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 �- Initiatin Devices Total r No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KWNo.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local[IConnnectioln ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of WaterKWo.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: s0 Q'_ (When required by municipal policy.) �J Work to Start: i i 3 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 cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 6n r-i Qoe MC�r'rAro pec �Ei c�f LIC.NO.: 61-91 6 Licensee: Signature LIC.NO.: C41"16 C) (If applicable,enter 'exempt"in the license number line.) Bus.Tel.No.:178-746-9M Address: 1 T W�r faw Ave—, 6 r0o,I A � Oda 1 Alt.Tel.No.: � *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 gent. Ccs Owner/Agent PERMIT FEE: $ Signature Telephone No. COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN I i ISSUES THE ABOVE LICENSE TO: .-NRIQU'E MARRERO JR 79t. tcr,' :f_N AVE rn' ROC`K1'ON MA 023E l°-6456 40164 E 07/31/13 877095 �-` ' ",.�CI�;T,�, � «�t' , r �•, y � Vii]j�;r�7 I I�k.\l ( 85689901 412201 11* " 19 -P- y ,CLASS R�'Sf MGT. Sb(�� * D .'B MARS0111bCT rMAss ENRIQUE M 794 WARREN AVE BRQ&TON,MA ' 12311-C45G f 'r 1d r The Conimonivealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 ivivivanass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Li lectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: 13(-)C L-1J A M h 3 of Phone#: 2 7e-7&b'' -'f`/�( Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction em to ees full and/or part-time).* have hired the sub-contractors ,-. -Zen p y ( p ) listed on the attached sheet.t 7 LS nen!°deling 2,Z I am a sole proprietor or partner- ship and have no employees These sub-contractors have S. E]Demolition, working for me in any capacity. workers'comp.insurance. 9. n Building addition are a corporation and its 5. We rp 'ions o workers comp.insurance ❑ 10.0 Electrical repairs or additions [No officers have exercised their required.] 11.❑Plumbing rein airs or additions 3.❑I am a homeowner doing all work right of exemption per MGL p myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs I f employees.[No workers'insurance required.] 13.0 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 ani an en�ployer that isproviding workers'compensation insurance far nay employees. Below is thepolicy and job site information.Insurance Company Name: /,�l Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: pity/State/Zip: -` Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 DTA.for insurance coverage verification. I do hereby cert fy under the pains and penalties of perjury that the information provided above is true and correct. Si ature: -_ Date' Rhone# jtj 7� lull� '��j��1 Official use only. Do not write ill this area,to be completed by city or town official. City or Town: PermitfUcense 0 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#: