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Home My WebLink AboutMiscellaneous - 177 WINTER STREET 4/30/2018.r s i Date.��.....d t ° <+`'° ;• "� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ✓ % n {�'� &i4cerfifies that' ........... ................//..— '? r ?........................ has permission to perforna.................. wiring in the building of.........l...:/��...............:........................................ at . /ZZ ........................................ r .............. , North Andover, Mass. Fee Lic. No. -- '. ELECTRICALINSPECTOR Check # fb 7653 ti _ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked L r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] 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: 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) roll�� 5� Owner or Tenant A toogiLt f7 t'pe , Telephone No. Owner's Address /Z?y•' ^J�i' 3 fr-: /— Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box) Purpose of Building Utility Authorization No.A&S— a Existing Service _&L Amps Yv Volts Overhead Lam' Undgrd ❑ No. of Meters New Service dO-0 Amps lad / Ci O Volts Overhead P�— Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: jW1k4-*1 504w, Completion of the following table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. of Ceil.-Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency ig ung Batter Units No. of Receptacle Outlets 03 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges ` No. of Air Cond. Tons l No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mun'c'pal ❑ Other Connection No. of Dryers l Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: 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: (When required by municipal policy.) Work to Start: 7-15-- 1`7 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 certify, under the pains and penalties of perjury, that the information on this application is true and completes�/ FIRM NAME: /ey �Y,r-C77•r—V /ter)ri<< LIC. NO.J`7W%,,� Licensee: 10;-e -1 `i --s 17 czn Signature LIC. NO.: //Y (If applicable enter "exempt" in the license number e.) Bus. Tel. No.: 0!'3(V F9i% Address: ,2 PG�ii►6.0.j % ofAtu"' Alt. Tel. No.:" . 440 now *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. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ak i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leyibly Name (Business/Organization/individual): 14%,4wf ir'�`r,;be—C,�- Address: City/State/Zip: & rgA rJ , 0.4 0t d S Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I emplgyees (full and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ 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 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy infonnation. 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: Policy # or Self -ins. Lic. #: Job Site 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. I do hereby cfy unglop4he pains and penalties of perjury that the information provided above is true and correct. 9s� 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 #: