HomeMy WebLinkAboutMiscellaneous - 24 GREAT OAK STREET 4/30/20185
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I 0'140 Date....
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3:;t':�`` -{'. a"�O� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SSAC"US�
This certifies that ......%�//'7 w..:. `�........ . .............................. r
s
has permission to perform„
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wiring in the building of .......%.......�.........................
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......��:.�o....-..................................................... North Andover,
Fee.....s. ......... Lic. No 3Z 2.......
ELECTRICAL I PECTOR
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Check # U�
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COMMonwealth Of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Utticial Use Only---'
Permit No. /,,// yd
®g g� °� p g Occupancy and Fee Checked
APPLICATION I®Iii ��9�, PERMIT'TO PERFORM ELECTRICAL
1/07] (leaveblank)----_
All work to be performed in accordance with the Massachusetts�tsElectrical Code NEC), 527 CMR 12.00 RK
(PLEASE PMTflVArl; OR TYPE ALL WO
RW Date:
City or Town of. NORTH ANDOVEP-
Bythis application the undersigned gives notice of his or her intention to perform the To the electrical work eCtOr Of lesci described below.
Location (Street & Number) ay
G Gr „tk S�-
Owner or Tenant
Owner's Address Telephone No.
Is this permit in conjunction with a building permit? es
Purpose of Building❑ No C5" (Check Appropriate Box)
—�e St too n r•o Y
Utility Authorization No. _ / � � � 2 6 9 �
Existing Service �p_ fps `a0 / Volts
Hn Overhead � Undgrd ❑ No. of Meters
New Sere'—ce �?� APs / 'Meters OverheadET . Und rd
Number of Feeders and.Ampacity g ❑ No, of Meters 3
Location and Nature of Proposed Electrical Work
No. of Recessed Luminaires
mom tenon of the followin
No. of Ceil: Sus p. (Paddle) Fans
table may be waived by the Iris ector o
No. of /Wires.
No. of Luminaire OutletsTransformers
No. of Hot Tubs
Total
R�r,A
No. of Luminaires
Swimming Pool Above
e ❑ in-
Generators RVA
o. o mergency
— No. of Receptacle Outlets
d
rg
Batte Units g
No. of Oil Burners
No, of Switches
No, of Gas Burners
P ALARMS No. of Wines •
No.
No, of Ranges
No. of Air Cond. Total
of Detection and �—
Imtiatin Devices .
No. of Waste Disposers
P
Heat Pum Tons
p Number
No. of Alerting Devices
No, of Dishwashers
.Tons KW No. of Self -Contained
Totals: ___......_....._. _._. _..._........_.._. . _..
Detection/Alertin Devices
Space/Area Heating KW
Local ❑ Municipal
No. of Dryers
Heating Appliances
Connection Other
No. of Water
KW
Security Systems:*
Heaters KW
No.. of No. of
No. of Devices or E uivalent
No. Hydromassage BathtubsNo.
S, s Ballasts.
No. of Motors
Data Wiring:
of Devices or E uivalent
OTR:
Total HP
Telecommunications Wiring;
No. of Devices or Eanival.,..*
Estimated Value of Electrical Work: Attach additional detail if desired; or as required by the Inspedtor of Wires.
Work to Start: (When required by municipal policy.)
fi S147° Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE; Unless waived by the owner no e
the licensee.providesproof of liability P unit for the performance of electrical work may issue unless
undersigned certifies that such cove tY �S {or e including
has exhibited pcompleted �oof of same to thecoverage or its is substantial equivalent. The
CHECK ONE: INSURANCE Permit sumg office.
I certify, BOND ❑ OTHER ❑ (Specify:)
under the pains and penalties ofperjury, that the information on th' a
FIRM NAME: �" t n PPlcadon is true and complete
Licensee: DO W n LIC. NO.:
LIC. NO.: I;
a
(If applicable, enter "exempt"in the lice number line) Signature
Address:
*Per M.G.L c. 147, s. 57-61, security work requires D 0 Bus. Tel. No.: a
OWNER'S INSURANCE W ePa►tment of Public afeAlt.ense: Tel
WAIVER: I am aware that the Licensee does not have the liability Lic. No.
required bylaw. By my signature below, I hereby waive this requirement. I am the (check one msuorance coverage normally
-------
Owner/Agent
Signature ) ❑ caner0 owner's agent.
Telephone No. PERMIT FEE. S < 0
ELECTRICAL PERMIT No. INSPECTION REPORT:
ELECTRICAL INSPECTOR --DOUG SMALL
1. ROUGH INSPECTION:
Re -inspection required ($50.00)
Inspectors' commenfs: .
(Inspectors' Signature - no initials) Date
d...�•,.,..rau �u.tl ur JGL A 1 V!V �
aaavu — t J .uauea —
11 Inspectors' comments: -'
(inspectors' Sid
nature - no initials
iuire($50.00) - [ ]
Date
DOOR TAGS ARE TO BE FTLLED.OUT AND LE
FT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
The Commonwealth of Massahitselts
Department of Industrial Accidents
Office ofl-nvestigations
..400 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
Applicant Information
Please Pri><at I.e ibl�
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am 'a general contractor
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
and I
have hired the sub -contractors
listed
partner-
on the attached sheet I
ship and have no employees
These subcontractors have
working for me in any capacity.
workers' comp, insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
myself. [No workers' comp,
right of exemption per MGL
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No JrJorkers'
comp. insurance required.]
;AMY
;AMY 2 plicant that checks box #1 must also fill out the section be a-� sho:rW;
h b ' b their wo-�°
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. El Building addition
10. [1 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roofrepairs
13. [1 Other
w o su mit tuts affidavit indicating they are doing all work and then hire outside contractors must submita new affidavit indicating such.
oirm
$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
information insurance for my employees Below is the 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).
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 certify under the pains and penalties of perjury that the information provided above is true and correct
ne_.. _.
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 Hearth 2. Building Department 3. Ci
6. Other ty/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person:
Phone