The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 1653 Salem Street S � s !�' -�- G 48420 ® p4 www.pendaflex.com MADE IN USA 30%PCW CutLesse File Folder e FEWER PAPER CUTS �''�2� !v o ��'� Date... ......f.{1 ................ NcnrH TOWN OF NORTH ANDOVER a PERMIT FOR WIRING gB�cMug� This certifies that t� t j.d..U t) ................ .. .. ............ . has permission to perform .. .(�".. .. .... �4...� 4�...................................... ngin the building of........'� i?`Q.t ,.............................................................................. w7 a ..... ...... ..4✓1.... .:.................................. orth Andover,Mass. Fee.. ........Lic.No �. ...m ........... ..... ..... .. .. . .....�- .... ELE CAL INSPECTOR F Check# 11540 Commonwealth of Massachusetts official Use only Permit No. Department of Fire Services 1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CI\ 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 1,3 113 City or Town of: NORTH ANDOVER To the Inspector of Wi es: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)) )�S �;A4 u k Owner or TenantA yzkT� )t F A ILS Telephone No. Owner's Address Z(,") Poty-o, d A(L dirvc� Is this permit in conjunction with a building permit? Yes ❑ No (Check Ap ropripate Box) l Purpose of Building Utility Authorization No�lq� I-7-77 1 - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service / ° 0 Amps 1 10 /2Z O Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �� Completion of the following table maybe waived by the Inspector of Wires. Trans No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above [] In- o.o mergency Lighting No.of Luminaires Swimming Pool 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 nudInitiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices. MunicNo.of Dishwashers Space/Area Heating KW Local❑ Connect oln ❑ Other No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent jj No.of Water KW No.of No.of Data Wiring: ti,{ Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: N y No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of 9 res. Estimated Value o lectrical Work: 56 0 (When required by municipal policy.) Work to Start: 2 G,I 13 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: 1NSURANCE"Q BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties of perjury,that the information on this application is true and complete. FHMNAME: . LIC.NO.: Licensee: bA o w-i-z, Sign LIC.NO.: qO6 (If applicab ente "exe t"in the license nu ber ine.) .� 0 Bus.Tel.No.: Address: (5 tX �n A 1�-1` : 6�-'C U"l�. �1�4� Alt.Tel.No.&2 T *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S SINSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally a required by law. By my signature below,I hereby waive this requirement. I am the(check one)EI owner El owner's gent. Owner/Agent PERMIT FEE: ,$ c,.,,,.,�,,, Te]enhnne Nn. f ❑ 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 accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation 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 of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he 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 entity stated 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 purpose 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: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass n Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass n Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: n 1 Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE TION: Pass Failed '❑ Re-Inspection Required($.)❑ Inspectors Comme . o -- l Inspectors Signature: Date: \DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com .t The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Lessibly Name(Business/Organization/Individual),.OL U1, Address: City/State/Zip: �a r . l�1c, a l VA15' Phone 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 employees full and/or part-time).* have hired the sub-contractors ( P ) 7. E]Remodeling 2.[ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub-contractors have 8. E]Demolition workingfor me in any capacity. workers' comp.insurance. 9. E]'Building addition [No workers' comp.insurance 5• E] We are a corporation oration and its 10.E1 Electrical repairs or additions required.] officers have exercised their ht of exemption per MGL 11.❑Plumbing repairs or additions 3.Elri I am a homeowner doing all work g p p myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information. Al 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 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. / ]Si re: ter' Date: 2-3 3 Phone#: " 1-2A^ ng b6o 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - Contact Person: Phone#: Information and Instruction s 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 employeris 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 local 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-contractors)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 carry 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. AIso 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 number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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 aff davit 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 or 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.02111 TeX.#61.7-727-4900 oxt 406 or 1-87TMASSAFE Revised 5-26-05 Fax#617-727-7749 www.znass,gavldia �fcd MdwwtALT (��NigS A HUSETT;S ELECTRICIANS REG JOURNEYMA ELECTRlC1AP ; rISSUES THE ABOVE LICENSE TO j LOUIS J` DADD' ' a 2<2 BIXB"+.�A`ENUE N,QRTH . ANDOVER MA u'ra4,5 2 J 3 r" -9 P 4 )I 1 :.. tC�hllI4NWETH OElvlASSETTS ELECTR1C1A1l� , A A REG JOURNEYMAN EIECTRICI�IP `�! IS SUES THE%ABOVE LICENSE TO L-DUI J `;DADDARTD !R 22: BIXB'4'`-AVENUE tvQRTH DOVER MA4�—? J r . CONTROL# H p 16 7 6 IMPORTANT If this license is lost or destroyed, notify . Division of Professional Licensure Y°tir Board at the: Suite 710;Boston;,MA 02118-6100. 1000 Washington St., If your name or address shown is changed, notify Of correct name or address to insure proper Your board If Application. Always refer tour license number.mailing of next This license is subject to the provisionsofthe General Laws (as amended.Itis�4 personal privilege,and must not be loaned r assigned to anv otherperson. Keep this license on or posted a!;required by law. your. p ' J !a 4• " 1 / ,J 1