HomeMy WebLinkAboutMiscellaneous - 171 CORTLAND DRIVE 4/30/2018 BUILDING FILE
945
Date.�A ' �.`J..
f NOR7M
:°•,fe``°:' "°o� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
SSACHUS
This certifies tha ............" `h�......... ' -'�� .�
has permission to r .................................
wiring in the building of.... ✓I.. �� ........................................
at./.7e.......Ca✓.... ..,[:G-,X......;� ,North Andover,Mass.
r Fee...�V-`
......... Lic.No...... .?.. ... ........ ......
ELE RICALINSPECTOR
Commonwealth of Massachusetts ot�cial UsERE= e Only
Department of Fire Services Permit No. . I
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] Qeave 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 vY
(PLEASE PRINTINM OR TYPE ALL INFORMAT1OA9 Date: 4 t
- City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice ofhis or her intention to perform the electrical work described below.
Location(Street&Number) /.2 � /, , )44n1-Irl v/
Owner or Tenant ��t
" Telephone No.
Owner's Address J -71 (91e
Is this permit in conjunction with a building permit? yes (vI
Purpose of Building ,� r4 No (Check Appropriate Box)
Utility Authorization No.
Existing ServiceZ;4r Amps /-ZU/ I(DVolts Overhead
❑ Undgrd No.of Meters �
F New Service Amps. / volts
�! l ❑ ❑
Number of Feeders and.Ampacity Overhead Undgrd No.of Meters
Location and Nature of Proposed Electrical Work: ✓ / `' /J�/
Completion oft e ollowin table mgy be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of CeiL-Soap.(Paddle)Fans o.of Total
D Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs V Generators KVA
No.of Luminaires Swimming Pool Above In- o.o mergency g
d• [:] nd. LJ Batte Units
--. No,of Receptacle Outlets /.), No.of Oil Burners
FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o.of Detection and ,Cl/
. ke
No.of Ranges � No.of Air Cond. °� Initintin Devices
'�- Tons No.of Alerting Devices
No,of Waste Disposerseat PUMP Number Tons KW o.of Self-Contained'
Totals: -- -`" Detection/Alertin Devices
No,of Dishwashers O Space/Area Heating KW ❑ Municipal
Connection ❑ Other
No.of Dryers 0 Heating Appliances KW Security Systems;* _
No.of Water No.of No.of Devices or Equivalent
Signs Bal
Heaters KW aof Data Wiring:
llasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total gp Telecommunications Wiring; 1
j�
OTHER: E No.of Devices or uivalent
U1
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— (/ t_p___�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
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent Thess
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E& BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FARM NAME: L J .!�' 1 c 71�•.` �.a 7<<a c%o.,s
LIC.NO.: 1,95'o M)Z
Licensee: ,��6d J-7--4�� Signature
(If applicable, eAter"exempt"in the icense number line.) LIC.NO.:
Address: 31 ,F;,.,,+,L}�,G ,,1`rA 1 �V/ Bus.Tel.No.:
*Per M.G.L c. 147,s.57-6 1,security work requires Departrnent of Public Safety"S"License: Alt.
L cl 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/Agent ( ) ❑owner ❑ owner's agent.
Signature Telephone No. PERMIT FEE: S
r
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I
The Commonwealth of Massachusetts
Department o f Industrial Accidents
Office of Investigations
600 Washington Street
Bostopz, 111.4 02111
WWW.massgoV1 a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PI
Applicant Information umbers
r Please Print LeQibiv
Name (B usiness/organizatim Individual): Lj ,
Addl`esS: Vie- J
�nT ✓,c
City/State/Zip: �j� / ; .--, 05.9 V
5 Phone#:
Are you an employer?Check the appropriate box:
1.❑ I am a employer with_ 4. ❑ I am a F7 []
e of project(required):
and I
employees(full and/or part-time).* have hired the sub-contractors
❑Nevi+construction
2•( I am a sole proprietor or arin,r- listed on
P the attache')
ttached sheet x Remodeling
ship and have no employees These sub—contractors have
working for me in any capacity. workers .
com g' ❑Demolition
[No workers' comp. insurance 5. We are a P insurance.
❑ corporation and its 9• X Building addition
3.❑ required.] officers have exercised their 10•❑Electrical repairs or additions
I am a homeowner doing all work
right of ex
emption per MGL .11.❑Plumbing repairs or additions
myself, [Nonworkers' comp. c. 152,§1(4).anwe have no
insurance required.] t em to ee 12-ElRoof repairs
P Y s. [No workers
comp.insurance required] 13.7 Other
:A-),applicPat thst Checks box#1 ma-t elo RE,on-.1�
homeowners who submit g e are os.+helot! w eu^^g �A orkms'com-...s-zioc
this affidavit indicatin the; are do;--aL'wcrs and
Contractors that cowl:this box must attached an additional sheet show o tee°hire otttside contractors rfus submit anew afdavit indicating such.
the name of the sub-contra„^tcm and their workers'comp.policy information.
I am an employer that is providing workers'compensation
information. insurance for my employees Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#.
Expiration Date:
Job Site Address:
Attach a copy of the workers'compensation policy declaration ane sho City/State/Zip:
licy
Failure to secure coverage as required under Section 25A of MGL . 152can1 d totheoimpos number
nbof criminal matron date).
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the foam of a STOP WORK ORDER and a fine
penalties of a
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 p • anenalties o er u n thcat the io
� d p fP .1 �' f rmation provided above is true and correct
Signature
Date.:._. V/"
Phone#: & 7,1 /S—6 77 3
[16.
fficial use only. Do not write in this area, to be completed bl,citj,or town offecial
ita or Town PermitUcense#
suinb Authority(circle one):
Board of Health 2.Buildinb Department 3. Citv/Town Clerk 4. Electrical Inspector 5.PlumbiriR
Other b Inspector
ntact Person:
Phone#: