HomeMy WebLinkAboutMiscellaneous - 64 SECOND STREET 4/30/2018 64 SECOND STREET
210/019.0-0009-0000.0
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HORTM
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACMUSE�
This certifies that .........M!4m.xo.LA......... ......
1 "7�"'
has permission to perform ............ ...............Q.........................�.......
wiring in the building of S.�19/<' .,...
.......................... ...... .............................
at...4 (/ ..SE'C6rLb........77..................... .Nprth Andover,Mass.
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Fee.... 11'�.." Lic.No....l A0�.ZA............ ..
� ELE RICALINSPECTOR
Check #
10779
9(-12012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with theprovisions of M.G.L.c.143,'§.3L,the
Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed' "
on the prescribed form.After a permit application has been accer .�by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation. C ked on the permit application.Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§ 1 r
Permits shall_be limited as to the time of ongoing constraction.activity,and mhy7ae.deemed_bythe Insp.ector_of_Wires abandoned_and.immlidMe—.
or she has detennined that the authorized work has not commenced or has not progressed during the preceding 12 month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote j&growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain-permits•and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effector existence"during the qualifying period beginning on August 15,2008.and extending'through August 15,20 2.
e —Permit(Date Closed: Note:Reapply for new perms
❑Permit Extension A.ct—Permit/Date Closed: \\
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•��=3 .�> �ePa.rt,rterrf o�_J`ire�ervice:s i
'��-�:" Oc,upanc� and Fee Checked
`t< BOARD OF FIRE PREVENTION REGULATIONS (Rey. '. 071 lc•_ e Lank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
:\fl\wrk to 1>e performed in acroriance \c il'.the\Sa<jaClaisetts Eiectrica'. Ce f\]:.C). �"C\SR I'_,o0
TYPE.-1 LL 1:\-Fi)R.:L-t 7'10A't Date:
Cite or Town of: �0(L'(� Prnl 4�a�t- To the ]nV)ec1or•of IFires:
B\ this application the Lilldersigned gives notice of hi;or her intention to perform the electrical work described belo\y.
Location (Street& \umber) 4 C0In0 SA--\
Owner or Tenant Telephone No. 2 �1�
Ownet•'s Address
is this permit in conjunction witj I uildi no,permit' Yes No ❑ (Check Appropriate ON)
Purpose of Building I IV'\\ 1 Utility authorization \o._
Existing Service Amps /aaayo\olts Overhead Undgrd❑ No. of deters
New Service Amps \'alts Overhead❑ Undgrd ❑ No.of deters
Number of Feeders and Ampacity
G Location and Nature Proposed Ele •ical Work: �$
L
Coro?letion ofthe;olloirirto table mety be r.zzic d br the hupecior of 1f fires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fats No. of Total
Transformers NA'A
No.of Luminaire Outlets No.of Hot Tubs Generators N\'A
No. of Luminaires SR'l1llIltlltg Pool above ❑ In- ❑ : o.o Emergency Ig iting
n nd. Qrlid. Battery !.-nits
No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
•f
No.of Switches No. of Gas Burners No.of Detection and
Initiating, Devices
No. of Ranges No.of Air n Cond. Tons No.of Alerting Devices G
No.of\Vaste Disposers Heat Pump Numbe{• ,Totts K\\' _ To. of Self-Contained
Totals: ; Detection/Alerting Devices
No.of Dishwashers Space/Area Heating K\\' Im inicipal
I b Local❑ Connection D Other
No. of Dryers Heating Appliances K\\: Security Systems:* �(
No. of Nater a. D
o. of No. of No of Devices or E uivalent
Heaters K\\` Data
\\'firing:
Signs Ballasts No,of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP
To
\\'icing:
No.of Devices or E uivalent
OTHER:
nosh additional de roil if desired,or cis required b_r the/nspector of'Wires.
Estimated \'aloe of E ectrical Work: G (When required by municipal policy.)
Work to Start: 3 inspections to be requested in accordance with NIEC Rule 10,and upon completion.
INSURANCE COV RAGE: 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 equivaient. The
undersigned certifies that such c yerage is in force.and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE- BOND ❑ OTHER ❑ (Specif}:)
1 certify,under the pains and penalties of perjury, that the information ou this application is trite and complete {{
FiRNI NAiIE:_ // jf� ��eCT-A* LIC. NO.:1Ot�/Z
Licensee: A,kESignatut LIC. NO.:
ljcg�plicabic. , ercTiVehl,01 PIlily hc•rrrc,j 1011 r(�r111re �,AU�6te.. Bus. Tel. No.^f �
Address: /LIW A (
A/1eX/ M &1p7�
Alt.Tel. No.:
"Per M.G.L. c. 147.s. 57-61. security work requires Department of Public Safet\ '•S•• Licettse: Lic. No.
O\\'NER'S iNSL'RANCE \\:\I\'ER: I am aware that the i.icensee ekes not hure the liability insurance coverage normally
required b\ iaw. By my signature below. I hereby waive this regt)irement. I am the(check one) ❑owner ❑owner s agent.
Ois ner/.-\gent
Signature Telephone No. EE: S 35 —
The Commonwealth oflh.ssuchusetfs
Depurtmew of'lii(Ilisti,i(ii.-tc,(-ideiits
Office ofln vesti(,(ttiolls
.
-1 1- 600 Washinalon Street
7
Bostoii, MA 02111
Workers' Compensation Insurance Affidavit: 13ititclei-.s/C'otiti-actot-s`/Electi-ici,,-Iii.s,/I)Itiiiil)ci-s
Applicant Information please Print Legibly
M111le
A mac 4 Ceco ec
,� ,�i
Cl-,\ Slm.-/Z ip: Ak, An kveZ
�23
Are you an employer? Check the appropriate box: i TN pe of project(required)
am a em-L)Iover N\;ih4. 1 ani I gene!a! collzi,�Moi,Z-111d I
Nev, consi, !illi
-nnt),ovees (fits and:()I-part-tiire).� ha\;-- hired -.�Ie ;Zldo-co:� ,t- S
6.
, t ;
I El
listed on he attached sheet. RemodeinI an, a iole proprietor or P,111CI, g,
Ship and have no emplovee" Theso-,,U`�-CC)lltl-,IMI-S h,%,\Ci 8. J Demolition
Wo!,king forme 11-1 at)% capaclt\• emq)loyees and have Nv(),Kel'S
lNo worke:-S Comp. Insurance comp. ins,!rance.-
We ave a covoora-,;on,and i--s
ME] Electrical repairs o:-
's i
required.] Lj officers Ila\-�;exercised 1he;l-
I am a homeowner doin2 al I \\ork 1.�7' Numbing repairs or addiilnns
im self. [No workers' colli p. ol'exeptioNIGL
j7 Roof
nsuranczrequired.] c. 15'1 §1(4), and e have no 1
employees. fNo workel's, 13.! 1 Other
comp. Insurance requin-ed.-i
"Anvapplica,,it that--necks box=1 mus!also till out lite section b-'10\% polic\ xi.
110111,owlers\,,Ilo Submit thisaffidav:i indicating ihev art Joinzail\\orkand then hilCCIUBIe must lw\%
.Corua.to7s that check This box must attached an additional sheet Sho\tm2,!-,name orth- state whoine! ornot ihoseelutes have
elllplo\ees li'die cnipi,1\0es.they must pro%iL their cons:.1),)];C\ MMl'X1.
I am an emploVer that is providin-workers'compensation insill'(117cefor m employees. Below is the poliev turd job site
information.
Insurance Company Mine: Aq R-rrm b
PolicN =or Self-ins. Lic. z: 94 WCe-.Pz 6 3 33 Expiration Date:
Job Site Address: �Co n 0 ST Ciu\ Srale Zip:
Attach a copy of the workers' compensation policy declaration page(shoNNiriu the policy number and expiration date).
Fai!utz to secure coverage as required under Section?5A of MGL c. 152 can lead to-.1he imposition o'err"Imal penalties of a
fille Lip*10 S 1.5,00.00 and,.or one-year Impri soil ZIS We!! =s civil penalties In the forn, of a STOP WORK ORDER an! a fine
or tip to 5250.00 a day aLnins,the violator. Be advised that 9 copy of this siatemen-L ma\ be forwarded to the Office of
Investigations of the DIA for insurance coveraie verification.
J do hereb-il certify ut/Zer the pt yrs and penalties of perjury that the information provided above is true and correct.
S i,-)r al I I re: c --Da-e:
Phone
-9 9OF M3
Ofjicial use onIV. Do not write in this area, to he completed hY city or it)wn official
GIN or To%\n: Permit/License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CitN/ToN\n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone i-;: II