The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 25 CIDERPRESS WAY 4/30/2018O6UJ Date ..........�.. Z..... �l ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. ..'.. '.......... ..............�............. has permission to perform .... �.................. wiring in thiVGifd jSf ,��f�. �. .. ' "••s �i �i ..� d . �„�. at . z>........ ....... ! . ........ , North Andov r, Mass: Fee3 �:. yi�.. Lic. No .? ��.`.: ............r.� : f�."..... ""I,1................ /ELECTRICALINSPE OR Check # %US'I Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEY), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 9 `U 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 & Owner or Tenant Owner's Address Is this permit in ca Purpose of Building (<e -J I Utility Authorization No. Existing Service Amps Volts New Service Amps / Volts `' Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters ocation and Nature of Proposed Electrical Work: x.11 14E, 7*` -A" I�EDuS?!5- IC Completion of the following table may be waived by the Inspector of 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 Above In- Swimming Pool rnd. ❑ rnd. ❑ No.of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 Alerting Devices No. of Waste Disposers Heat Pump INP.Tber Tons KWNo. ....................... of Self -Contained Totals: 1 Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local EJ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters 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 Inspectorof Wires. Estimated Value of Electrical Work: (FC)00. M (When required by municipal policy.) Work to Start: I L t,4 t t. I 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 for , and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: M,44f g!adgLawc LIC. NO.: -44. Aeok Licensee: A(,CK¢E t.-471j��ignature LIC. NO.: Z7 S'17 (Ifapplicab enter "exempt" in the license number line.) Bus. el. No.• — % Address: S mws N Alt. Tel. No.: fp~Oar *Per M.G.L c. 147, s. 57-61, secur' y 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 Owner/Agent PERMIT FEE. $ Signature Telephone No. I jo 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): AA -*,C- IS Address: City/State/Zip: V_ S i!?,v_ a,q a-tY!E,- Phone #: c(? g Are you an employer? Check the appropriate box: 1. M 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. [Kew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ttAA DO 4---- %_N S C-0 Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Z.SG[�Gr1.PK.BSS S± -Z sd City/State/Zip: AI(), A-Z')j) Attach a copy of the workers' compensation policy declalation 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 certW under the pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # L 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 #: