HomeMy WebLinkAboutMiscellaneous - 258 BRIDGES LANE 4/30/20182012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance- ith the provisions of M.G.L. c. 143, §, 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughoutthe Commonwealth, and applications shall be filed •
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. 01 c. 166, § 32, an
electrical permit shall he issued to the person, four or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L, c. 143, § 3L.
Permits shalLbelimited as to the time of.ongoing construction -activity, and may be.deemed-by-the snspector_of_Wires abandoned-and.in olid-ifhe—...
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be temminated upon the written
request of either the owner or the installing entity stated on the. permit application.
❑ The Permit Extension Act was created by Section 173 of Clmapter 240 of the Acts of 2010 and extended by Sections -74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job,growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain -permits -and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008.and extending through August 15, 2012.
11—PermitfDate Closed: V&W . (�" - �L` *** Note: Reapply for new
0 Permit Extension Act—Permit/Date Closed:
,9823
Date. 1(.)-. gn 1C).........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... U.4&....... ..............................
has permission to perform .... .. ..............................................
wiring in the building of .....
. - . 1.
at ... 4� .......... .... A 74 ............................. vJbIGg do
An ver, Mass.
Fee ... 5,-.0 .......... Lic...........
Ei CAL INSPEMR
Check it
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. X 7 -
Occupancy and Fee Checked
[Rev. 1/07] leave blank
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 I1V INK OR TYPE ALL INFO TION) Date: % l 0
City or Town of:aff'orn To the Inspecto of Wires:
By this application the undersi ,dgivss-not eOhis or her intention/to perform the electrical work described below.
Location (Street & Number) �J ��t D 6P (,/-1-,U �, I Q 7 e(,
Owner or Tenant AA -0 A "2-e4j ,M /4-C A LJ (ZTelephone No. 3 y c) L
Owner's Address
Is this permit in conjunction with a building permit? Yes 1 �o ❑ BLDG PERMIT #
Purpose of Building 'Pe- -g 1 [) .9-,v �.? Utility Authorization No.
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
U A, f Z 0 0 n -t . IQe_Avo 14-'i- l a n1
COmDletion of the fnllowinu tnhlp mnv he wnivad by the T—n—inv .,f Li;—
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- Elo.
rnd. rnd.
o Emergency Lighting
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches or
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting 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 El 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 E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical W4r3 Oj 0 r CO (When required by municipal policy.)
Work to Start: f (' Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VE GE: 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.
,HECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
certf, under the pains and penalties of perjury, that the information o is application is true and complete&
FIRM NAME:% AQv u,- L e cB'!z c LIC. NO.: /' 002
Licensee: 0 p"ILr ]-, P aA A, C,,9 Signature LIC. NO.:
(If applicable, enter "e empt" in the license number line.) Bus. Tel. No.:4
Address: S A --p CD utr Alt. Tel. No.: a3- b 3XV
*Per M.G.L. c. 147, s. 57-61, security w rk requires Dep ent of Public Safety "S" Licen 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
Signature Telephone No. PERMIT FEE: $ �O
The Commonwealth of Massachusetts
Department of Industrial.Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/.lElectri.cians/Pluma:bers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): _' >v Q U _eJ � Le GrlLI t,
Address: 10ALe- ') T-
City/State/Zip: A n./V o w- Phone #: cl � b - LO J — `f ! 9 J_
Are you an employer? Check the appropriate box:
1." I am a employer with �7__
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. ❑ X 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.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ELP doling .
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. [J Roof repairs
13.❑ Other
•-ri.ny applicant that checks box #1 must also tilt 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 isproviding workers' compensation insurance for my employees Below is the policy and job site
Information.
!nsurance Company Name: 4 ' C o
Policy # or Self -ins. Lic. #:
Job Site Address: �' a R q) % ej G 4- N
Expiration Date:I a 3 /. (
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
a
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 fo�asurance coverage verification.
X do hereby certify
pains andpenaldes ofperjury that the information provided above is true and correct.
It >b-L�a_�-�3J--D
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
rssuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ __ hone 9: 11