The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 678 MASSACHUSETTS AVENUE 4/30/2018 678 MASSACHUSETTS AVENUE 210/059.0-0066-0000.0 • Date./07..,2..-.a? + TOWN OF NORTH ANDOVER PERMIT FOR WIRING US is certifies that .. ........ ... ............................. has permission to perform ...'7�. ... .......... U wiring in the building of. ......................................................... ................................................................... North Andover,Mass. 0 —17 Fee,6 ................... ... ............. Lic.N . . .... . . .......... EL cTRICAL INSPECTOR Check # 9047 -� commonwealth of Massachusetts Official Use Only Department of Fire Services Pern"t No. ri Occupancy and Fee Checkeda� BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 IN INK OR TYPE ALL INFORMATION) Date:7 �ires:City or Town of. NORTH ANDOVER To the Inspector of By this application the undersigned gives;lotice of his or her intention to perform the electrical work described below. Location(Street&Number) S v Owner or Tenant • ug-s-1/2. 0Owner's Address Telephone No. Is this permit in conjunction with a b 'ding permit? Yes ❑ No �y 1=.1 (Cb k Appropriate Box) Purpose of Building Utility Authorrd izatio ` Existing Service ,j Q Amps Q/ Volts Overhead Und g ❑ No.of Meters New Service Amps l &Volts Overhead Undgrd ❑ No,of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: _4A P i Completion o the followin 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 AboveElIn- ❑ o.o mergency ig g d• nd. Battery Units -- No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches No.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: -_........._..........._..................._................-. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of No.of Devices or Equivalent Heaters KW No.of Data Wiring: Signs Ballasts. No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors. Total Hp Telecommunications Wiring: OTHER: No.of Devices or E uivalent `4 i Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: (` Signature l _ LIC.NO.: (If app icable, nter" emp�" 'n the lice a num er li e.) Address: �` Bus.Tel No.: $- ?7 *Per M.G.L C. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt.L cl.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: ,$�j�av The Commonwealth of Massachusetts Department of Industrial Accidents 1 , �I Office of Investigations 600 Washington Street ' Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers A Iicant Information Please Print Leaibl NameBusiness/Di 1 ( ganization/[ndividuai}; (` Address: (� S City/State/Zip �ff.� D l ��/� Phone#: --62 65— k1,3 Are you an employer?Check the appropriate box: Type of project(required) i.❑ I tam a employer with 4. ❑ i am a general contractor and I employees(full and/or part-time).* have hired 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 subcontractors have 8. ❑Demolition working for mein any capacity, workers' comp.insurance. [No workers'comp, insurance 5. ❑ We are a corporation and its 9 ❑Building addition required.] officers have exercised their 104D'lectrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No•worke'rs'comp, c. 1.52, §1(4),and we have no 12. Roof insurance required.)t ❑ repairs eq ] employees. [No.workers' comp. insurance required..] 13-El Other'Any applicant that checks ba#1 must also fill out the section below showing their workers'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 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. Lic.#: 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 a pains and penalties of perjury that the information provided above is true and correct. Si ture: Phone#: ------------------------- 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): L Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: