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Home My WebLink AboutMiscellaneous - 320 BOXFORD STREET 4/30/2018 / 320 BOXFORD STREET / 210/104.B-0013-0000.0 Date ./....: ,�1 ... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRINUq ,SSACHU`�� ' This certifies that ......A)&e4..... .......................... has permission to perform �' Avi'L �j� ................................... ...................................... wiring in the buildingg o—f— .S....�`t��....).f...�•S4.-�-� .......................... at.. .....!� f"rW.. ............................ orth Andover,M S. Fee i ....... Lic.No.. .......Y................P.,. , ELECrRICAL MpECTOR Check 11 $4 10427 N Common-wealth of Massachusetts Official Use Only Permit No. /0 Ll 2_7 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 0,av,bl'ank) 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 PRINTINNK OR TYPEALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfotin the electrical work described below. Location(Street&Number) Sc?<-) �EeK�(jrd ��= A, 9(kY_5—_ Owner or Tenant A t -q Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Utility W1 (Check Appropriate Box) t, Purpose of Building ty Xuthorization No. Existing Service 0240 Amps / —,V0 Volts Overhead UndgrdF❑-1 No.of Meters Ir New Service Amps Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: 00 IV/- C/ Completion ofthe following table may he waived by the Inspector of Wires. No:of Recessed Lumin-airess No.of Cefl.-Susp.(Pauddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ICDA No.of Luminaires Swimming Pool Above -�E] No.of Emergenc liting grnd. ❑ arnd. ❑ BatteryUnits No.of Receptacle Outlets No.of 0111 B1Jrne_r117 F—IPY,ALARMS INo.of Zones No.of Switches No.of Gas Burners No..of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number I Tons J.K.W.......... No.of Self-Contained Totals:F...... Detection/Alerting Devices Municipal F] Oth No.of Dishwashers Space/Area Heating KW Local[:] M4' er C01111MEM o No.of Dryers Heating Appliances KW Security Systems:* - No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: 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 Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: / /,, 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: INSUP-A-NCEE] BONDEI OTHEREI (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: . ILLact ..,e Signature LIC.NO.: oXPQAO (If applicable,eXer"exempt-,,in the license number line.) Bus.Tel.No.:7&Lc2,?9-,5_ Address: /r? LM t 1/1 S �t Ec/tl" Alt.Tel.No.:711-PSY207 Y4 *Per M.G.L c.147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.7k-- 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) El owner E1 oi�Eer'--e The Corsamoi2rvealth ofMassachusetts Department of Industrial Accidents y a Office of Investigations IV P, � 600 Washington Street L{5� Boston, MA 02111 www.hzassgov/dia . Workers' Compensation Insurance Affidavit:Builders/ContrafarsXlectricians/Plumbers A • :Iicant Information Please Print LE bl Name (Business/Organization/individual): Address: City/State/Zig: Phone#:. Are you an employer?Check.the appropriate box: 1,❑ I-dm'a employer with_ 4, general T ype project(required): 1 emiloyees(full and/or part-time).* ❑ have hired the sub-contractorsconor and ew construction 2•❑ I am-a-sole proprietor.or partner_ listed on the attached sheet. emodelingship and.have no employees These suh-contractors haveI working for me in any capacity, workers' comp.insurance. emolition[No workers'comp,insurance 5. ❑ We are a corporation and its ilding additionrequired] officers have dxercised their ctrical re airs or additi3.❑ I din a homeowner doing all work right of exemption per Mons GL mbing repairs or additionsmyself,jNo workers'comp, c. t52, §1(4);and we have noinsurance-re uired. # of repairsq ] employees, [No workers' er camp, insurancerequired_] eAny applicant that checks boa'#l must also frit out the section below showing their workers'bompensation policy information, t Homeowndre Who suhmit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box tnustattnehed en additior-al shber showiaag t-ho rsne of the subcontractors and their comp.poli. I arm an elrvsptnyer that is prgtrisling;wor,+teP3'coat, errsaaa ra information.. ieasuratrlrefo' y"10yees; Bed®w is the policy-and job s&e ' Puranee Company Name, ' Policy#or Self-ins.Lie. #: • Expiration Bate: - • Job Site Address: 4 • City/State/Zip: Attach a copy of the workers'compeasmtion 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- #ine 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 DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 3ienature: Date: Phone#: Official case only. Do not .write in skis area,to be co;,,plgted by[i%y or tt7wit 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.Ut6er, Contact Person: Phone#: • t 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 Informationrr Please Print Lelzibly Name (Business/Organization/Individual): A j C-kO#ct Address: ? o'� 1M t Gu a City/State/Zip: Re Phone Are you an employer?Check the appropriate box: Type of project(required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 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. # 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL I L❑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 box#1 must also fill out the section below showing their workers'compensation policy information. f 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.#: Expiration Date: 1 - ,, Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Pup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certi under t pains and pe a ties of perjury that the information provided above is true and correct. ature: Date: 4• ial use only. Do not write in this area,to be completed by city or town official. Town: Permit/License# Authority(circle one): 3 of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector r person: Phone#: