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64 GREENE STREET
210/043.0-00240000.0
�.. Date..7..`.. .:.�1�......
NORTH
;6�"a TOWN OF NORTH ANDOVER
YN` FO a e P
PERMIT FOR WIRING
i o p��.• �j
., �,SSACHUS� 4.
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Thiscertifies that ...... � ................................................ . ............................. 4
has permission to perform .. _-�.�' - c ... ..............................................
wiring in the building of........ `�......'. :4. y':c'..............................................
at..Com:`/.......,.............:.... ...................... ,North Andover,Mass. '
Fee r?/rti Lic.No..//�� �f ........... ... .....
ELECTRICAL INSPE
Check #
2
9270 a
Commonwealth of Massachusetts Official Use 0
a my
Department of Fire Services Permit No._ � 7U
E BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _
[Rev. 1/07
� (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
'' E WORK
All work to be performed in accordance with the Massachusetts Electrical Code�(MEC) 527 CTRI�A 00 YY OR1�
j� (PLEASE PRINT LV flVK OR TYPE ALL INFOR MTIOA9 D
City or Town of: NORTH ANDOVER ate. i' !U
By this application the undersigned 'vex notice of his or her intention to perform the o the Ins
ectn��of
moires:
Location (Street&Number) work described below.
Ste.
Owner or Tenantj-
Owner's Address /rte Telephone No.
/ca�1
Is this permit in conjunction with a building permit? Yes
NO
Purpose o Check
m'p f Building j jn�`� ��,�`�1 nc, ( Appropriate Box)
Existing Service AUtility A
uthorization No.
mPs iGVlOverhead L�O
Undgrd❑ No,of Meters ._
New Service Amps / _Volts
Overhead❑ Undgrd ❑ No,of Meters
Number of Feeders and.Ampacity
Location and Nature of Pr .t
orosed Electrical Work:
(2,
Com
Com letion o the ollowin table maybe waived b the Inspector of Wires.
No.of Recessed Luminaires No.of CeiL-Sus No.of
p.(Paddle)Fans Total
No.of Luminaire OutletsTransformers ICDA
No.of Hot Tubs Generators KVA
No.of Luminaires Swimming pool Above ❑ In- o,o mergency
d. d• 11 Batte Units g
--. No.of Receptacle Outlets
No.of Oil Burners FIRE ALA 2WIS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
No.of RangesNo.of Air Cond. Initiatin Devices
°�
No.of Waste Disposers HeaTons No.of Alerting Devices
t Pump Number Tons
Totals: """""" o•of Sell-Contained
No.of Dishwashers _� _ ___. Detection/Alertin Devices
` Space/Area Heating KW Local❑ Municipal
No.of Dryers Heating A Connection Other
Appliances KW Security Systems:*
No.of Water. No.of No.of Devices or E uivalent
Heaters �'
Si s BallNo,asts of Data Wiring;
.
No.Hydromassage Bathtubs No.of Devices or E uivalent
g No.of Motors Total Hp No.
Wiring:
OTHER: No.of Devices or Equivalent
Estimated Value of lee .'cal Work: Attach additional detail if desired, oras required by the Inspector of Wires.
' Work to Start / ted (When required by municipal policy
Inspections to be requested in accordance with MEC Rule 10,and upon completion.
IN�'SURANCE VERAGE: 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,�ove�a is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Imo' BOND ❑ OTHER
I certify, under the pains andpenalties o ❑ .(Specify:) .
P fP�%ury, that the information on this application is true and complete
FIRM NAME: (/c,� e(,C� _� PP
Licensee: J f C 11 t. LIC.NO.: �f
h!•(' � y cC� Signature 7
(If applicable, enter exe p "to the license number lin .) LIC.NO.:
Address: , — / x its.Tel No. 7 '7L/,2�7
*Per M.G. c. 147,s.57-61,security work re �rl • .�
qwires Departrnent of Public Safety"S"License: AIL
L c?No.
OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have the liability insurance covers e
required by law. By my signature below,I hereby waive this requirement. I am the normally
check one g 's agnt.
Owner/Ag
Signatureer7� ( one) EI ❑ownerele hone No. j60-7i(; 7P PERMIT FEE: .S'
e
S
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A
The Commonwealth of MassachusettsDepartment of Industrial Accidents
Dice of investigations
r ire 600 lCirshington Street.
Boston, MA 02111
c; www rnass.gov/dia .
Workers' Compensation Insurance Affidavit: Budders/Contractors/Eiectricians/Pinm
Applicant
Information bars
l Please Print Leaibl
Natlle(Business/Organird66n/Individual): L, iJ��L`(,�C� .
•.&C 1 CAL-
Address.
City/State/Z.iP•-gm-et4l ve-t-' 114A 8
Phone#:_2;7�
Are you an employer?Cheek.the appropriate box:
I•[] I am a employer with 4. ❑ I am a general contractor and I Type of project(required):
_ mploYees(full and/or part-time).* have hired the sub-eon Tactors 6 ❑New construc4on
2•JIIJ I am.a.soie proprietor or partner_ listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These stns-contractors have
working for me in an 8. Q Demolition
y capacity. workers' comp.insurance.
[No workers'comp.insurance5. ❑ We are a corporation and its 9• ❑Building addition
required-] officers have exercised their 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work right o#"exemption per MGL I I.❑ Plumbing repairs or additions
�YseIi~ [No workers'comp. c. L52, §I(4),'and we have no
insurance required.]t employees. [Noworkers' 12.0 Roof repairs
' comp. insurance:requin4] 13•❑Other
Any applicant that checks boi#l must also tilt out the section below showing their workers'com
t Homeowners who submit this affidavit indicatirt they are loin a!) pensation policy information
Contractors that check this box must g °i g work end than hire outside contractors must submit a new affidavit indica*
attached an additional sheet show
I iqg the rtp�rre of the snb.corrr cte! ora tti_i w� , such
` rv�+4�,.��i7,,inibrtnation.
a►n an employer that is prgviding:warkers'compensation insurance or
inforrnadon. } �'employees: Below is the Policy and job site
i Insurance Company Name.
Policy 4 or Self-ins.Lie.#:_� U I7 3 YA 3 2
09 lI
l iration Date: 1® .
Job Site Ad
dress:
Attach
e copy of the wor
kers compensation policy declaration page(showing the policy number and expiration date
Failure to secure coverage as required under Section 25A of MGL e.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 farm of a STOP WORK ORDER and a f
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 fine
Investigations of the DIA for insurance coverage verification.
I do hereby certify u der the pains and penalties o/Perlw,'that the information provided above istrue and conte
Sienatra
Date:
Phone# CC"
Ofj°tciat use Only. Do not write in this area,to be completed by.city or town o c[aL
City or Town:
Issuing Authority(circle one): Permit/License#
I. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing lnspeetor
6.Other
Contact Person:
Phone#;