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Home My WebLink AboutMiscellaneous - 350 WINTHROP AVENUE 4/30/2018 (20)0 Date ... )..bI .... ...... i . ( .. G—.. . ..... . ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Spi\u This certifies that ......... ... .... . ............. . . ..... . �,-hA . . .................................... ;rl ............................................. 1, ATi r has permission to .... if:ll ............. AAwiring in the building 0 le ................ ................................... t ...................... ... ...... . -�at 55VO� - )�� 'I C, ..... . . orth Andover, Mas ....................................... !�� ............. ...... u ...../'..... Lic. No. . ... ...... . .. . ............... ..... 4 Fee................. .. .. Check # "351 1 3n A, 8 TRICAL INSPECTOR ,zt Commonwealth of Massachusetts = Department of Fire Services 0 a BOARD OF FIRE PREVENTION REGULATIONS Official UseOn Permit No. G6 Occupancy and Fee Checked [Rev. 1/071 (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 INNK OR TYPE ALL )NFORMATION) Date: ) - k, �' 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,�b W Lel, �S' Cs� vel` caner r Tenant - V l,:' 7 iA -,S, OF LTO Telephone No.:�1 .�, - Owner's Address e--,f�4-r si' Is this permit in conjunction with a building permit? tz w b5 -A U- ,Yn CM Yes ❑ No ❑ (Check Purpose of Building Utility Authorization No. - Existing Service Amps LyT / 2.65 Volts New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Ap 4 x No. of Me rs No. of Me %moi -lam Completion ofthe following table may be waived by the Inspector 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 Swimming Pool Above ❑ In- ElBatter rnd. rnd. o. o mergency ig ting Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. . Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons J.KW ............ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Secu tNo.o Systems:* Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector oi wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1- g A 5— 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 2 BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and penalties of penury, that the information on this application is true and complete. FIRM NAME:ELF L LIC. NO.: �4 1.2.5 L b Licensee: ��i�,�,Q, r b, lv� ��1 �, Signatur�_,��,� LTC. NO.: (-x,'1.2�� (7f applicable, enter "exempt" in the license number line) Bus. Tel. No.:1'z&2,r, ' 7 Address: ) 5sl C ISL. 4S F&1; -b 5-'F- L,UA,r E 1.,L. m L zS 1 Alt. Tel. No.: CV 5,.3 y 1 *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: $ Z`� Signature Telephone No. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person tri the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore Of the .foregoing engaged in a joint enterprise, and including the legal representatives of a: deceased employex or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or loeal licensing agencyshall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificates)) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LL C or LLP does have employees, apolicyis required. Be advised that this affidavitmay be submitted to the Department of Industrial Accidents for conivmation of insurance coverage. Also be sure to sign and date the affidavit. 'phe affidavit should be returned to the city or town that the application for thepermit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be, sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill, out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in the pemalthicense number which will be used as a reference number. In addition, an applicant thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or tow:n). ".A: copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit4s on file .for future hermits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would Me to thauk you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number; Tho onwealthofMi,aSSavahmotts Depat`Gxxment of1hdu*!al Accidents ofte QUuirol< gAVO.I 60 Wa6i gtonSjre l Boston, MA. 02111 TO, # 617-72,74900 eyd 406 ox x-877,AF Revised 5-26-05 `ay, 617MM749 ' WWV�'.�,aSS,gc}vfc.�la �f � j .-- -- , ~~ / �| | ,Pe-,z �,,.+. 40