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2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordancewvith 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 maybe.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.
8 — Permit/Date Closed: ***Note: Reapply for new
0 Permit Extension .Fist — Permit/Date Closed:
Date.. 4n /...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............b o.. -v 0 v4�
.........................
has permission to perform ......... ......................................
wiring in the building of ................l. '.L.E..'.y..........................................
at ......./... .7.V 189Ad—G. e.6 .........5..P': ........ .. , rth Andover, M S.
'Fee....... �Lic.No.37,�,Q.r7.�............. . KXoELE
CALI SP
` 3 1/
Check #7
"10534
r
Commonwealth of /Massachusetts
l Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. `R57 3��
Occupancy and Fee Checked
[Rev. 1/071 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 ININK OR TYPE ALL INFORMATION) Date: 1.2,113
City or Town of: NORTH ANDOVER To the Inspector o fres:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) / % y
Owner or Tenant �� Telephone No.
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service /CyvAmps �2 U Volts
New Service Amps / Volts
YNumber of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
4
Yes E��No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ® Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters %
No. of Meters
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- 1:1o.
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
Tons
J.KW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Municipal El Other
Connection
No. bf Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No.(of WaterKW
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.
Esti ated 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
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:)
I cert, under the pains anti penalties of perjury, that the information on this a ation is true and complete.
FIRM NA LIC. NO.:
Licensee: - t Signatur LIC. NO.: k -2G
(Ifapplicable, enter "exempt" in (he nse number linj) Bus. Tel. No.:
Address: .3 c � lice_S' c S k010 hl /n QS F?Alt. Tel. No.:17k 2 y
*Per M.G.L c. 147, s. 57-61, security work requires Departrfienrof 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. $
w
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builckrs/Contrac
Name (Business/Organization/Individual):
Address:
rs/Electricians/Plumbers
J
Please Print Le
City/State/Zip y.r S b 0 y Vft IA Phone #:
Arou a Toyer? Check the appropriate box:
I.- m a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contactors
2. am a sole proprietor or partner-
'listed on the attached sheet. t
4 ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. [1 We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
*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 the policy and job site
information.
Insurance Company Name:A,4,oc) Fo r j
Policy # or Self -ins. Lic. #:
J�b Site Address
Expiration Date:
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.
ereby certify ende�ihe '' s ndpenal s of perjury that the information provideed above is true and correct.
ure: ''�Date: / �������
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 #:
