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Home My WebLink AboutMiscellaneous - 70 Main Street (2) BUILDING FILE Date........................................... NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,sSACHU This certifies that ...... ...... ....................... has permission to perform ........... ... . ...... .................................................................. wiring in the building fq e _f L of.,..,. Al�.... ...jl ,< 7��........................................... .7p.......&-i-A.........:5 North Andover,Mass. at ........... .................................................. No Fee...... ............Lic.No. .......... ELECTRICAL INSPECTOR Check# 22-3 5" 12604-1 Commonwealth of Massachusetts Official Use Only Department of Fire Services hermit No. BOARD OF FIRE PREVENTION REGULATIONS ccupancy and l=ee Checked (Please add zip codes & electrician's cell#; O [Ree. 1,071 contract# & b/d permit#if applicable. (Ie ive bl"nk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 011 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:- / City or Town of: 41a.,-AA %7f f�t�l To the ln.spectol Q Wires: By this application the undersigned gives notice of his or her intention to pertbrm the electrical work described below. Location (Street& Number) S-7— Owner or Tenant �, �/ � �'��r� � Telephone No. Owner's Address Is this permit in conjunction with a building permit'' Yes Fr No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 1y3;7 -z-, -1 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters \Z New Service /g26 Amps Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �- � �� 1/ -7—�j9ar JV Completion o/llie%allouinL tablemol:he waived hr the ln.c pector of Wil.c. No. of Recessed Luminaires No.of Ced.-Susp. (Paddle) Fans No. ot Total Transformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o. o Emergency .►g ng No. of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No. of Receptacle OutletsNo. of Oil Burners FIREALARMS No. of Zones No. of Switches No.of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number 'Tons KW No. oSelf-Contained Totals: � ....... ' ..... ... .t-*................... Detection/Alerting Devices No. of Dishwashers ace/Area Heating Local Municipal p g KW ❑ Connection Ottet. No. of Dryers Heating Appliances KW SecuriNo.ty Systems:* 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 Wiring: No.of Devices or Equivalent OTHER: Attach additional detail i/desired• or as required hr the Inspector of Wirer. ,Z4 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 proofof liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force and has exhibited b 6 b ted roof of same to the permit issuing office. P I b CHECK ONE: INSURANCE ❑ BOND ❑ OTHER X❑ (Specify:) General Liability 12/31/15 I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Boissonneault Electric Corp. LIC. NO.: 11823A Licensee: f��,RG'�" - A4�,,�"/saa Signature (//applicable, enter ••exempt"in the license number line.) Bus. Tel. No.: (978)454-0353 Address. 36 Chuck Drive- Dracut, MA 01826 Alt. Tel. No.:_(978)458-9977 *Security System Contractor License required for this work: ifapplicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes 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 �} Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conh-actot•s/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/h,dividual): Boissonneault Electric Corp. Address: 36 Chuck Drive - P.O. Box 639 City/State/Zip: Dracut, MA 01826 _ phone#: 978-454-0383 ArerL-�Vlarn an employer? Check the appropriate box: 1. h m a employer with 4. ❑ I aa general contractor and I Type of project (required): employees (full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.+ ❑ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l 1.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑Roof repairs r insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box tr I must also fill out the section below showing their workers'computsatiOil policy inlivnuttion. t I lomcowners who submit this affidavit indicating they arc doing all work and then hire outside contractors mus(submit it new alfidavit indicatingsuch. Coil tractors that check this lx)x must attached an additional sheet showing the name of the sub-con(ractoi:s and state whether or nol those en(itics have employees. II'the sub-contractors have employees,they must provide Iheir workcLi-s'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Utica National Insurance Group Policy# or Self-ins. L,ic. #;4386559 - _-__- _ -- - Expiration Date: 1/1/16 Job Site Address: /� S City/State/Zip:"g �Jtr�G�� .1•��' ®/ �"� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (late). Failure to secure coverage as required tinder Section 25A of MGL c. 152 call 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 line Of up to $250.00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office o1' Investigations of the DIA for insurance coverage verification. do hereby cert• ' under the pains and penalties of perjury that the inf n-ination provided above is trite and correct. Signature-. Date: I / Phone #: 978-4540383 Official use only. Do not write in this area, to be completed by city or torn 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#: t LTH OF MASSAC US-S. , • • • • - • • • I: RICIANS .. ISSUES THE FOLLOWING L.10E'N'SE AS A REGISfiERED MASTR. ELECTRICIAN .00,14.SONEAULT ELECTRIC CORP NORMAND. . 8(?15SONNEAULT PO 90X 639 Dki, UT MA 01826-o639 1 182 :; A . ` 01/11/16 :. 32609 MM WFJILTH OF M:. US :: . ETTS: NEW URI Lei • - • • • >I ANS ISSUES THE FOLLOW[NG :.:LICENSE AS Ar`REG JOURNEYMAN ELECTRICIAN- NORMAND D SOISSONNEAULT Po Box 639 DRACUT MA 01826-0639 24696. E .: 0 9. 6 2610 7/3,.1:x13 �v i