HomeMy WebLinkAboutMiscellaneous - 4 First Street. 9727
Date ... 1p -:n -al -7-4e
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ P L . j
has permission to perform .......... ....... 4 ...............
wiring in the blgWing of ....... ...................................
...... 6r ....................... . rth Andover, Mass.,
at ....... Y ...... Mlqf
(7,7
-10 .........
Fee ... Lic. No . .. .... .. 717 ELi�
Check # 2—qf-5�'
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Department (of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
' M
Permit No. 67-761,
Occupancy and Fee Checked
[Rev. 1/071 (leave blank)
APPLICATION FOR PERMH TO PERIFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC , 527 CMR 12.00
(PLEASE PRINT.ININK OR TYPE.ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the lnspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the elee ical work described below.
'o( s✓
Location (Street & Number)
Owner or Tenant
Owner's Address SA
'f2
Telephone No.
Is this permit in conjunction with a uilding permit? Yes E] No Er (Check Appropriate Box)
Purpose of Building CoAr'n2 es, ot"14d Utility Authorizatibn No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:' g -
/N �sr�/�r ,�alrr SAT c,�c` its .jlt/1LLf
ir of,)A
y 2e -,o
0
nf'tlna fnYnv);ma Mhlo mnv ha waived by the Insnector of
Attach additional detail f deszrea, or as requirea oy the inspector of rrtreo.
Estimated Value of Ele trica Work: (When required by municipal policy.)'
Work to Start: (0 o`t (0 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 c v ge 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: u22o e IeC-fr. LIC. NO. -_L2- 7 7 9-�
Licensee: 400-A', ,T pv2Z-. Signature LIC. NO.: L- 27.32 3
(If applicahle, enter "ex mpt" in the license number line.) Bus. Tel. No. ;DE 3/7. 931 7
Address: f0 Go¢..i W ,,4Nawer ,,NJ � Fyy Alt. Tel. No.: « 6�?- ??dam
*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
Owner/Agent PERMIT�. $
Signature Telephone No.
No. of Total
No. of Recessed Luminaires
No. of Ceil: Sus addle Fans
P• )
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool r Rrnd.
o. o mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection andInitiating
No. of Switches
No. of Gas Burners
Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pum P
Number
Tons
No. of Self -Contained
No. of Waste Disposers
P
Totals:
"
J.KW
...•...•.•.•
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal Connection El Other
No. of Dryers
Y
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
KW
No. of -No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications
of Devices or Equivalent
OTHER:
Attach additional detail f deszrea, or as requirea oy the inspector of rrtreo.
Estimated Value of Ele trica Work: (When required by municipal policy.)'
Work to Start: (0 o`t (0 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 c v ge 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: u22o e IeC-fr. LIC. NO. -_L2- 7 7 9-�
Licensee: 400-A', ,T pv2Z-. Signature LIC. NO.: L- 27.32 3
(If applicahle, enter "ex mpt" in the license number line.) Bus. Tel. No. ;DE 3/7. 931 7
Address: f0 Go¢..i W ,,4Nawer ,,NJ � Fyy Alt. Tel. No.: « 6�?- ??dam
*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
Owner/Agent PERMIT�. $
Signature Telephone No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):_
Address: f0 cz:Yf U t
rUZZ o �,�2Pi�'c�
Please Print
City/State/Zip: p` A lud of r IM Phone #: / W- 3 / 2` 1�93 tl 7
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I 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. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I 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.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. F1 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box 41 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.
$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. Lie. #: 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 $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 hereby certify under the p ins a penalties of perjury that the information provided above is true and correct.
Signature: Date:
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
I
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