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Home My WebLink AboutMiscellaneous - 33 FOREST STREET 4/30/2018 (2)Of NOR7q 1� • O � p ,SSAcMUSf Date....Il.' ..Z..-./�.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING r This certifies that ................li (�1�!✓� ri2l... Or-, F�! ................ has permission to perform ....."�. {%.� /Ot ,P4-� ............................................ wiring in the building of ......... eQ LC ........................................................... at 33..... E �5-e----------- 5,7.' ............................ . NorthaAndover,�Mass. Fee.:3 .. Lic. No.�.%..P................. l,w � . . ........... E ECTRICAL INSPP,TOR 'iCheck N 10437 (ommonwealth o f //laajacwetb Official Use Only Apad.d o f -ire Service.4 Permit No. /o`er 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 (MEC), 537 CMR 12.00 (PLEASE PRINT IN INK OR TYPr 4 7k ALI, FORMATION) Date: ,3 City or Town of: da To the Inspecto offires: By this application the undersigned gives notice o his or her intention to perform the electrical work described below. Location (Street & Number) �3 3 55,— �.—' Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ �] Telephone No. (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps IdOl olts Overhead �� Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters l Location and Nature of Proposed Electrical Work: Comnletinn nfthe fnllnwina tnhla —, hn —;-d h„ ill, D, i.,.. lIII-- No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVO► No. of Luminaires Swimming Pool Above ElIn- ❑ rnd. rnd. o. o mergency ig ing Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of netectlon 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 TonsKW ""....... .'"""" " No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Municipal [I [I Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water Heaters KW o. of No. o 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: � j 1 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: LIC. NO.:.,Ziisd Licensee:,v SignatureLIC. NO.: (Ifapplicable, enter "exempt" in the li ense number line.) Bus. Tel. No.: Address: 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. $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washin-n Street Boston, MA 02111 printM t Fnrrn ' w>71w.mass. c ov/dia In Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:_ tate/Zip: Phone #: Are ,you an employer? Check the appropriate box: ❑ I 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 These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.# required.) 3. ❑ I am a homeowner doing all work myself. No workers' comp. insurance required.) t ❑ 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 reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.7 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation pdiicy 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 boa: must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees; they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for mi) employees. Below is the police and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: 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 S 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 5250.00 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 certify under thepains andpenalties ofperjury that the information provided above is true and correc4 Sivnature: Date: Phone #: IN 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 Person: Phone #: