HomeMy WebLinkAboutMiscellaneous - 506 BOSTON STREET 4/30/2018 506 BOSTON STREET
/ 210/107.D-0079-0000.0
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Date...... ..�`�....�. .....
O NO DTM
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
��Ss�cHUSE�
J
Thiscertifies that .............................................................................................
has permission to perform =-� � j � '
wiring in the building of.J�.:.....` � X '
................ ................................................
� North Andover Mass.
Fee.7".5..c .. Lic.No.:.../. �Zo .......... ... ... .. ...,
. . .... ..
LECTRIC L INSPE
Check # �-� 1/1?
868
Commonwealth of Massachusetts otcial e Only
Department of Fir Permit No. 9P
Fire Services ---
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 neaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 1A,
All work to be performed in accordance with the Massachusetts Electrical C WORK
Code MEC 5
27 CM
(MEC), R 12.00
(PLEASE PRINT ININKORTYPEALLINF01UMTION) Date: 9-pie-a�
City or Town of. NORTH ANDOVER To the
By this application the undersigned gives notice of This her intention to perform the Inspector
electrical work described below.
Location(Street&Number)
o6To11 s
Owner or Tenant
Telephone No.
Owner's Address /✓Vt
Is this permit in coniunction with a building permit? Yes No
❑ (Check Appropriate Bog)
Purpose of Building
Utility Authorization No.
Existing Service Amps / Volts Overhead
❑ Undgrd❑ No.of Meters
New Service Amps volts Overhead
❑ Und rd
g ❑ No,of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Completion of qd
hable may be waived b the Inspector o Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)FaNo.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ o,o mergency tg g
CL
Batte Units
No.of Receptacle Outlets No.of Oil BurnersFIRE ALARMS No.of Zones
No.of Switches No.of Gas BurnersNo..of Detection and
No.of Ran
Initiatin Devices
Ranges Total tal
No.of Air Co
red. Tons No.of Alerting Devices
No.of Waste Disposers Beat PSP Number Tons KW No.of Self-Contained
Totals: ""'w'" �� ' Municipal
���"�� Detechon/Alerttn Devices �
No.of Dishwashers Space/Area Heating KW Local
❑ Connection ❑ Other
No.of Dryers Heating AppliancesKW Security Systems:
No.of Water No.of No.of Devices or E uival mt.of
No
Heaters KWData Wiring;
Si s Ballasts . No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of MotorsTotal gp Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Stark 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 co v rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER
I cerci ,under th ❑ (Specify:)
fy pa' sand pen¢I 'es of p j ry, th¢ the information on this application is true and complete
FIRM NAME: 0, r�
p LIC.NO.:
Licensee: YI Signature
(If applicable, enter "exempt"in the license numb r line.) LIC.NO.: Z� C
Address: A a,V S �Lp� ��" 0 7-9 Bus.Tel.No.: LY y7p!//6'
*Per M.G. c. 147 s. 57 61 secure work requires D Alt.Tel.No.:
h q 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
Signature Telephone No. PERMIT FEE: $
;} The Commonwealth of Massachusetts
k- 1 Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, ALL 02111
www.nwss.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Narne (Business/Organizadon/individual):
Address: 0 U
City/State/Zip: �7�1,1(i1 �!T �3�� l Phone#•
Are you an employer?Check.the appropriate box:
1.13I am a employer with 4, 111 am a general contractor and I Type of project(required):
�empioyeea(full and/or part-time).* have Eared the sub-contractors 6. New construction
2. I am a.sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These suis-contractors have 8. Q Demolition
working for mein any capacity. workers' comp.insurance.
[No workers'comp. insurance S. 9• ❑Building addition
p ❑ We are a corporation and its
required.) officers have exercised their 10.F7 Electrical repairs oradditions
3.❑ I am a homeowner doing all work right of exemption per MOL 1 i.Q Plumbing repairs or additions
myself. [No-workers'comp. C. 152, §1(4),and we have no 12. Roof
insurance required.]t employee-s. ❑ repairs
[No workers'
camp. insurance required..] I31-1.0ther
'Any applicant that checks boi#1 must also fill out the section below showing their workets'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 mustattaehed an additional sheet show' the name of the sub-con
. _ ►� tractors and their workers`camp.policy information.
I ant an employer that is providtng:worlters'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 cert' un r the pains a enalties of perjury that the infnrnwtion provided above is true and correct
Si titre: / Date:
Phone#: / l 9 — / / 9"ll1
FaMealth
only. Do not write in this area,to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2. Building Department 3.City/Town Clerk 4.Electrical ins for 5. PluP� robin l g rrspector
son: Phone#;