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Home My WebLink AboutMiscellaneous - 32 ELMCREST ROAD 4/30/2018 32 ELMCREST ROAD 210/055.0-0031-0000.0 Date......gn—Z/'.f .... NORTI� °f'•``° '"a TOWN OF NORTH ANDOVER O 9 PERMIT FOR WIRING ,SSACHUSE� ...... ............/.�..J... 7' This certifies that ' "'A./.. ........ .................,......... has permission to perform wiring in the building of............. ...................................................... at.......................................::................................� ,North Andover,Mass. Fee..................... Lic.No. ....:. ............. .... ..... ................. i ELECTRICAL INSPECT(SR Check # 9231 Commonwealth of Massachusetts Official Use Only • Permit No. Z_ Department of Fire Services _ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to beP erformed in accordance with the Massachusetts Electrical Code(MEC),5 7 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z 2,o t O 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&Number) 3?- t M C t2E Sr Vz°A Owner or Tenant 9 O W E 1-L Telephone No. 9?0 S 96 31g Owner's Address 5A M Is this permit in conjunction with a building permit? Yes.-ErNo ❑ (Check Appropriate Box)' Purpose of Building Utility Authorization No. Existing Service (OO Amps- J ZD 240 Volts- Overhead a Undgrd-0. No.of Meters. 9 New Service Amps- / Volts Overhead-E] Undgrd&❑ No:of-Meters Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Work: PLY(&S t 0 0 Pr mhi+d P?OJ L /M,0 q 0001- Completion 00"Yt- Com letion o the followingtable ma be waived by the Ins ector 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 Swimmin Pool Above ❑ n- El o Emergency Lighting g rnd. rud. Battery Units No.of Receptacle Outlets I l No.of Oil Burners FIRE ALARMS No of Zones No.of Switches No.of Gas Burners No.of Detection an Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis osers eat Pump . -umber. ...,ons No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ uniecti El other P g Connection tSecurity ystems: No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.o atero.o o•o Data Wiring: Heaters KW Signs Ballasts No.of Devices or E uivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications irmg Y g No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of ElectTical Work: (When required by municipal policy.) Work to Start: 2 ti) 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 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,that the information on this application is true and complete. FIRM NAME: csGU e&6 6, M fl+ NOS r,t.EC(YLi(_ R LIC.NO.: (O 9 A Licensee: t` Q Signature LIC.NO.: (If applicable,eni "exem t"in the license number line. Bus.Tel.No.;6o�09 Z ZS �j 1 Address: O 1561 N5h!,tM NN 030'73 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 ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. t a ople 7, i I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street , t Boston, HA 02111 `t www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �� Please Print Leaibly Name (Business/Organization/Individual): 6`CJ{ Address: �� 6, U S zo City/State/Zip: �TK � lM N Phone #i: Are you an employer?Check the appropriate box: Type of project(required): employer with I.❑ 1 am a em 4. ❑ 1 am a general contractor and[ p Y 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2,'I am a sole proprietor or partner- listed on the attached sheet.$ F1 Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers' comp.insurance. 9, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 8% required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself [No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.)t .employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks bo>t fF l 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 infommdon. 1 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.#: Expiration Date: r 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 insur7 coverage verification. 1 do hereby certify under th p ' tvprnWiury that the information provided above is tue and correct Stafore: Date: Z f 20 (0 Q Phone#• 3 y C n o 9 ZZ S OfJFleial 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.CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: