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Home My WebLink AboutMiscellaneous - 21 HIGH STREET 4/30/2018 (32)N r 0 Date ......... Z.:....1.-1.3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...........� 1?.1�1.K... ..... G.......�..................................................... has permission to perform .........S.0........3................................................ wiring in the building of......... 6 ......................................................................................... at ...�+� ..,.......:.!.� 57— ............................................ ,�'�.............. . North Andover, Mass. ................. Fee .. ). �'S .�rLic. No. f .3.�.. `� .. J .4- .. -'. !. ,. l�..................., y ELECTRICAL %SPECT R Check # "?-79)0 lot 'i ,8a Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (ieaveblank 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: 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 cribed below. Location (Street & Number) v �- 2r �.,Z O 1 -- Owner or Tenant ��% �/,�Q Tel hone No. Owner's Address Is this permit in conjunction with a building permit? Yes t3 No ❑ (Check Appropriate Box) Purpose of Building f� Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity _ In Location and Nature of Proposed Electrical Work: Comnletion ofthe fnllowino tnhlo mnv ha wnivod by tho hivnortnr of Wirac 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- ❑ rnd, arnd. No. of Emergency Lighting 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alertin Devices g 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 ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent `� lw o. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent 7 OTHER: Attach additional detail if desired, or as required by the Inspector of Vires. 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE % BOND ❑ OTHER ❑ (Specify:) t certify, ander the pains and enaltie/s of erjury, th t the informati on tl ' lication is true and complete. FIRM NAME:. L A 4 lIV44 LIC. NO.: Licensee: - Signature LTC. NO.: (If applicable, enter "e e -v kc empt" in the lic nse nit ) Bus. Tel. No.• Address: o //t/ tel/ Alt. Tel. No.: *Per M.G. c. 147, s. 57-61, security work requires Department of Pub is 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 PERMIT FEE: $ Signature Telephone No. P The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations IN 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information Please Print Legibly Name (B, Address: City/State/Zip: A 0� /V C7�/� Phone #: A/% 9 Zi V 0 �;e�7 Are ou an employer? Check the appropriate box: 1. PI. am a employer with �_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 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 1011 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. I Homeowners who submit this affidavit indicating they aie 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.,$ite 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 requiredunder 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 certo under the paa nalties ofperjury that the information provided above is true and correct. Cionnfnrw 1.�e J nate• //!ve//__� 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 #: