HomeMy WebLinkAboutMiscellaneous - 230 FOREST STREET 4/30/2018 (2) 23UFUKtSI ��Kttt
210/106._0000.0
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j f AORT"1
o?°�;�`": TOWN OF NORTH ANDOVER
PERMIT 'FOR WIRING
CHUS
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This certifies that .........�..`'.. ........ f,J/t..!1 ��
has permission to perform ....... `Y—...6T, XM. ...�
a
wiring in the building of............ .!.4 ( ...........................................
at................................. ........................................ .. ,North Andover,Mass.
Fee..................... Lic.No....._�S^ .... ......... . .....f es!
ELECTRICAL INSPECTORV
Check # !" (L_.__.__
10450
i
vi
Commonwealth of Massachusetts Official Use Only
Fire
No.
Department of Fore Services
Occupancy and Fee Checked
k BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 Oeaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD
All work to be performed in accordance with the Massachusetts Electrical Code(ME ),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: �y
City or Town of: NORTH ANDOVER To the Inspeqtor of Wires:
By this application the undersigned gives notice of his or her intention to perfotm the electrical work described below.
Location(Street&Number) --I�- 230 1`G,(t'_S 1
Owner or Tenant J e 5 W�,I(w Telephone No.
Owner's Address SY3.�n�
Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box)
Purpose of Building 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
Location and Nature of Proposed Electrical Work:
. - �f��� S-�c vice N1-m!ffl��7� Sxow�
Completion of the following table may be waived by the Inspector of Wires.
Recessed T u inai f C l-a.. )r No.of Total j
No.of �,_�W res No.ea.eia. �..sg.(Paudle��+ans 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. Batter Units
— No.of Receptacle Outlets No.of Oil BuYners My,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 No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained
Totals: *------J--'** .......... Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:* -
• No.of Water No.of No.of No.of Devices or Equivalent
Heaters ' Data Wiring:
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.
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 th ins and penalties of perjury,that the in r 'anon®n th�`appl'cation is true and complete.
FIRM NAME: VLMcr5 IQM ate l t; LIC.NO.:
Licensee: T/1 UV"Irrs .,0Wlt"5 VtAic Signatur'WAW4A I LTC.NO.:
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: I ` '
Address:
Alt:Tel.No.-
*Per M.G.L c.147,s.57-61,security work requires Department of Public Safe 'S"License: Lic.No. __fie Il
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.
Owne.r/AQenf I _,__---_^_
- The Corrzrnonwerrlth of Massachusetts
f Department of Industrial Accidents
Office of Investigations
F 600 Washington Street
to ! g
{,�,�
Boston, MA 02111'
www hwss gov1dia .
Workers' Compensation Insititrunce Affidavit: Builders/Contractor°s/Eiectricians/Plumbers
Applicant Information
Please Print Le�bly
Nan a (Business/organization/Individua '
1},
Address:
City/State/Zip: Phone
FrUself
n employer?Cheek.the appropriate.box: '
*a employer with 4. ❑ I am a general contractor and I Tyle of project(required):
loyees{full and/orpart-time), have hired the sub-contractors6' ❑New construction
.a.sote proprietor.or partner- listed on the attached sheet 7• ❑Remodelmgarid.have no employees 'These sul3-eoniractors have $. ❑Demolitioning for me.in any capacity workers' comp.insurance.orkers'com .insurance 5. rp 9, ❑Building additionp ❑ We are a co oration and its red_] officers have exercised their 1Q.❑-Electrical repairsor additions
a homeowner doing alt work rightof exemption per MGI 11.j]PIumbing repairs or additions
M
Wwworkers'comp. c, t.52, §1(4),'and we have no 12.[]Roof repairs
insurance•required.]t .employees. [No workers'
comp. insurance required] 13.❑.Other
'Any applicant that checks bol-#1 must also fill out the section below showing their workers'bompensation policy information.
t Homeow irp who submit this affidavit indicating they am doing all'work and than hire outside contractors must submit anew affidavit indicating such.
Contractors that A-1,#14-L-..mustetteched an additional shyct showi 9 t_he nEme of the sub-contractor and their�ierka s'ceaff i avitpoliin;indicating
such.
1 arrt ayss ervapinyer that es py®vadlng:w®t Itepz'copt
infbrprasrtinn. penseadarg insuiatice j`ory� employees: Below is file policy-and job site
Insurance Company Name: '
Policy#or Self-ins.Lic,#: Expiration Date:
Job Site Address:
• City/State/Zip:
Attach a copy of the workers''compensation policy declaration page(showing the policy number and expiration date). 1!
Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a-
fine up to•$1,500.00 and/or one-year imprisonmenti 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerdify under thepains andpenalties q/'pedury that floe itsfnP>nation provided above is Prue and correct
Signature:•
Date:
Phone#:
Official use r�nly, Do not w.rye l�orfs area,
to be con, by cud or t,�wEInspnector
City or Town; Permit/LicensIssuing Authority{circle one):1.Board of Health 2.Building Department 3.City/Town Clerk 4.Ele5.Plumbing Inspectorb.OtherContact Person: Phone