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Home My WebLink AboutMiscellaneous - 24 Juniper Circlen� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . l�-.....I U t ,f T' i ✓►.. C.. ............................ has permission to perform p►-Y� e Ce wiring in the building of .. pv� � �ok ............................................. at.....1....... .�./....0 �................. ,North Andover, Mass. ee... .�.... Lic. No...... (. !n�'..................................:.... ELEC MCAL INsncroR .heck # 10594 •--t y� O 2j p .i7 U H p U Q U �? O W I� N a 1U-1 N •N o Pt N O 5'vi Pf y N U N bA{•' O bgqAN� o a m N° a o by tti Hca q C', o�caa� W m a� q y a A.H occ ❑ ;p- o OO ON. y F-1 q B O O. '� N .,y � N o ry pW� ti p m 5 a N a by O 40 HFU o 0 o .� bA0 Iq .d Q.,Ce�o A ••- �' � , p N 6 ci p O 9 .� c3 Up U.p o$ o o o w GI ao d i0i Qi N y' � O y U��` •0 ami W � 1 W � 1,•` E�-! in � q ° 8 5 - �„� y �N f']'firN W N uO ca A. a-.3 o `~ E O .0 X Uti.0 ' O k N U N GJ 2 O�J Ai �U1 04 4-1 N P. .O0 q P-� O cv +-� E •c � � � ' FM �i d6 00 ( oimnonw,,& of Ma33,w1weffj Official Use Only 1JePadwd of ,}im Ser ke6 Permit No. Oc BOARD OF FIRE PREVENTION REGULATIONS [Rev.l 07] upancy and Fee Checked UVleave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEq), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I � I `L City or Town of: ljt?m-k Am', ", To the Inspect of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 2q 3uW \P 6,-, Ct m l -C, Owner or Tenant Owner's Address &YJ kdv�S o,MA, b Is this permit in conjunction with a building permit? Yes Purpose of Building aj dmf G.E, S — U'- V" Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. No Ll(Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead E]Undgrd E] No. of Meters No. of Meters Aaacn aaatnonai aetatt q desired, or as required by the Inspector of Wires. Estimated Value of Electrical rk: (When required by municipal policy.) Work to Start: Inless I11�spections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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, thgt the information on th' applicq�on is true and complete. FIRM NAME: N �w. �I At -Th 1 r (.l l .1 I 1/1 Licensee: !tii t^3P. i (If applicable enter 11empIll . Address: w d *Per M.G.L. c. 147, s. 57-61, s OWNER'S INSURANCE W. required by law. By my signal Owner/Agent Signature Signature LIC. NO.: J ) i%1I \ LIC. NO.: �urrtuer carte./ - Bus. Tel. No.: L' V`--> 1 � N 10� Alt. Tel. No.: Drk requires Department of Public Safety "S" License: Lic. No. I am aware that the Licensee does not have the liability insurance coverage normally I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's agent. Telephone No. 03.%C1�0&I I PERMIT FEE. $ -1c) z. �.i YL eiac uuuwtrt tuute may be waived ov the inspector ol wires. 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- E] No. of Emergency Lighting rnd. zrnd. 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 Devices No. of Ranges TotaInitiatin No. of Air Cond. Tons l No. of Alerting Devices No. of Waste Disposers Heat Pump Number TonsKW........... 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. No. of Water No.KW No. No. of Devices or Equivalent Data Wiring: Ballasts Signs Ballas Si No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Aaacn aaatnonai aetatt q desired, or as required by the Inspector of Wires. Estimated Value of Electrical rk: (When required by municipal policy.) Work to Start: Inless I11�spections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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, thgt the information on th' applicq�on is true and complete. FIRM NAME: N �w. �I At -Th 1 r (.l l .1 I 1/1 Licensee: !tii t^3P. i (If applicable enter 11empIll . Address: w d *Per M.G.L. c. 147, s. 57-61, s OWNER'S INSURANCE W. required by law. By my signal Owner/Agent Signature Signature LIC. NO.: J ) i%1I \ LIC. NO.: �urrtuer carte./ - Bus. Tel. No.: L' V`--> 1 � N 10� Alt. Tel. No.: Drk requires Department of Public Safety "S" License: Lic. No. I am aware that the Licensee does not have the liability insurance coverage normally I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's agent. Telephone No. 03.%C1�0&I I PERMIT FEE. $ -1c) z. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 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 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. $ 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. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other Any appncam mat cnecKs oox IN must also till out the section below showing their workers' compensation policy information. 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 Address: 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 cert under the pains and penalties of perjury that the information provided above is true and correct Signature: Date 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 #: