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Home My WebLink AboutMiscellaneous - 21 COCHICHEWICK DRIVE 4/30/2018I M Date ... .Z..1�. .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................................................................................................................ has permission to perform .....)?Cl ,, .................. wiring in the building of.......... e at 2 1 1' 1 G !/'�` 'L- `' "Andover,..Mass... Mass. .......... ..................................................... CSJ Fwe.. �................ Lic. No. `.�UZ% ..................... .....ELEC �k # O) D Commonwealth of Massachusettts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ Occupancy, and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN )NK OR TYPE ALL INFORMATION) Date: WORK l 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) --21 C O CW C k w i c 9 r Owner or Tenant Telephone No. Owner's Address 11 Is this permit in conjunction with a building permit? Yes Purpose of Building L((; -,o No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service 1-->U Amps 1ec- / mOVolts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd E Undgrd ❑ Svb pct s e ( go' vies✓ iyccs� 4-s lr....__1_.. No. of Meters No. of Meters No. of Recessed Luminaires M u Ine uuuwm No. of Cel Susp. (Paddle) Fans tante may ae waived by the Inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o Emergency Lighting nd. 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 No. of Ranges No. of Air Cond. TotTons No. of Alerting Devices No. of Waste Disposers Heat Pump Number ....... _. .Tons KW No. of Self -Contained Totals:........_ Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: -- No. of Waterallas No. No. of Devices or Equivalent Heaters KW Si asts Sims Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices c E uivalent OTHER: Afiacn additional detail i desired, or as required by the Inspector of Wires. Estimated 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 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 pain--sII and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: N01 Cty; 2e `I e h, -r r LIC. NO.: Licensee: Signature LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.-, Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ t) it, The Commonpealth of Massachu eifs '- - Department of Zndiotrigl Accid nts Office of Invesfigations 600 Washington. Street Boston, MA 02111 U1 vWmmassgov/dia WQxkexs' Compensation Insurance Affidavit: Buffdexs/ContractoxslElectxzclauslPZumbers - ,A Meant Tnfoxmaiion Please Prim x,e 'bl i t j l�•e�� . Name (Business/Organizati-onftdividuai). N �� I C I�eY, Address: v -e_ City'/State/Zitp:1 G 1 SSW l G s Phone #: I G C)-� -q& S- S74/Cl Are you an employer? Check the appropriate box: 4. I am a general contractor and I 1. ❑ I amt a employer with __ __ mployees (full and/or part tame). have hire dthe, sub -contractors 2. I am. a sole proprietor or partoer- listed on the attached sheet. These sub -contractors have Alp and'have no employees working for me in. any capacity. -workers' comp. insurance. 5• ❑ We are a corporation and its [No workers' comp. Insurance ofhtcers have exercised their required.] 3. ❑ I am a homeowner doing all work .g p on right of exem tiper MGL myself. [Now comp. c.152, §1(4), and we have no employees. o workers' insurancerequired.] t comp. insurance required.] Type of project (required): 6. [] New construction F `i• ❑ Remodeling 8. [( Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions ii.❑ Plumbing repairs or additions 12. Q Roof repairs 13.❑ Other NAny applicant that checks box#1 must also fill outthe section bet6w showing their workers' compensation policy information i -Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. d an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. xContractors that checkthis box must attache X am an employer that is providing workers' compensation insurance for my employees:.Below is the,polley and jOb site information. Insurance Company Policy # or Self -ins. MG. Expiration Date: Job Site Address; . City/State/Zip: Attach a copy of the workers' compensatioxi policy declaration age (showing the policy number and expiration date). FaiWa to secure coverage as xequired.under Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/ox one-year imprisonment, as well as ciyR penalties in the form of a STOP WORK ORDER. and a fm of urs to $250.00 a day against the violator. Be advised that a copy of thus statement may be forwarded to the Office- of Investigations of the, DIA for insurance coverage verification. X do Hereby certify under tlae pcz s cM penalties ofpeY�ury that Me infarmatio�t pi ovicdecd alcove is true and correct. - Phone. b G3— q6 S 'Szl d Officzad use only. .Do not write in this area, to he completed by city or town official. City or Town: PermitJLicense # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone �r s 11 1 I 'I -- Commonwealth of Mas Dfvisron of.Profession us "s c ure Board of State f clans NOLAN 24 NORT W PLAISTO w Journeyma e 53208-B 07/31/2016 .aqM sv0v`0 License No. 00984 _Expiration Date. Serial No.