HomeMy WebLinkAboutMiscellaneous - 265 SALEM STREET 4/30/2018cn
Date."-,,.�/4.�*/�*�" ...........
TOWN OF NORTH ANDOVER
.PERMIT FOR WIRING
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........ ..... ........ ....... . ..... ....... . North Andover, Mass.
Lic. No.?.*10, ................................ I ....................................................
ELECTRIC AL IN SPECTOR
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2.patined / Jim Swvice6
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only,
Permit No. I -� 113 - �
Occupancy and Fee Checked
[Rev- 1/07] (leae 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 INFORMA TION) Date:
City or Town of. Alo.--Tlt 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 & Number) ZC5 StJe,,, 3-:1—
Owner or Tenant J�U;11 & Ft &r e- r A,, e-ra A�j- Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes 21' No F±1 (Check Appropriate Box)
Purpose of Budding Utility Authorization No.
Existing Service Amps volts Overhead R Undgrd 0
New Service Amps Volts Overhead Undgrd
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work:
a4d 17 kec-e-57'y 4�7f 4A d flA a&14 T- F,?.- 7-V 7—o
i�omvletion of the followinz table mav be waived bv the InsDector of Wires.
No. of Recessed Luminaires j3
No. of Cefl.-Susp. (Paddle) Fans
No. of Total
Transformers K -VA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming pool grnd. El grud. 0
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE AL�S
No. of Zones
No. of Switches
No. of Gas Burners
No. etection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
HeatFWm_P_FN_u.!R!?�K]X"�
Totals:
I
NY_
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Municipal
Connection 0 Other
No. of Dryers
Heating Appliances
t KW 06VIV
-ge—curity Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of
Signs Ballasts -
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
INo. of Motors Total EIP
T ommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desirea or as required by the Inspector of Wires.
Estimated Value of Electrical Work: k4Zca (When required by municipal policy,)
Work to Start: Z IU A( Ins'pections 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 force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCEE] BONDE] OTBEREI (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: Cacciola Electdc Corp. LIC. NO.: 20690-A
Licensee: Paul Cacciola —Signature
afapplicable, enter "exempt" in the license number line) Bus. Tel. No.: 781-858-9228
Address: - 4 Eric Drive Billedca Ma, 01821 Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security 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 E] owner's agent.
Owner/Agent
Signature Telephone No.-- [PERMIT FEE. S
AT
si I
al M,
The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'11� www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Cacciola Electric��rp
Name (Business/Organization/Individual): 1 1-11 i
Address:
City/State/Zlp: 11.�i I il ricaMa,,01821 Phone #.- [�, 781-858-9228
Are you an employer? Check the appropriate box:
1. 1 arn a employer with 3
4. 0 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. 1 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. 0 We are a corporation and its
required.]
officers have exercised their
3. 1 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. E3 Demolition
9. Building addition
10. Electrical repairs or additions
11. Plumbing repairs or 'additions
12. Roof repairs
13. Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation Policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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 insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name
Hartford
11_12WECG18352 - _' i
Policy # or Self -ins. Lic. Expiration Date:11'4W 4e�&7—]
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 h ereby certify under th e pains and penalties ofperjury that the information provided above is true and correct
Sip,nature: Date:
Phone
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
Phone #:
0
1.4
.1821