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Home My WebLink AboutMiscellaneous - 72 LISA LANE 4/30/2018 (2)N i R jaORT" Ogt.�ao ie,tiQ O Date....!:.. ?�.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that / has permission to perform �. ^ ............ .- cc c...: . wiring in the building of ... ..,s: ............................................. .- ........................ . North Andover, Mass. r� Fee . '�........ ...... Lic. No d ��1�..��.................................................. ....�.... ELECTRICAL INSPECTOR Check #/�1 S% 7777 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 2172— Occupancy 17 9Occupancy and Fee Checked [Rev. 1/071 (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: / — & " 0 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant 7^6" ov--d Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Telephone No. 9 X 77K 7/89 Yes No [] (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1014— "mss- f <,ic !- C � �y- Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (.Paddle) Fans o. OF— Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] rnd. rnd. o*o mergency ig ing Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. Of etection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Tons K No. ofSelf-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mun'cipal ❑ Other Connection No. of Dryers Heating Appliances Kir Security Systems:* No. of Devices or Equivalent No. of Water Kir No. of No. of Data Wiring: Heaters signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications iring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (JD �� (When required by municipal policy.) Work to Start: .�—g '?- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 9) BOND ❑ OTHER ❑ (Specify:) / certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: w e`(t [ r :S6;V(AA lj Signature LIC. NO.: '1;-)-;11!5-- (If (If applicable, enter "exem{tt" in heI'nse er line.) a Bus. Tel. No. - Address: Alt. Tel. No.:97 Y73dP t'.3 *Per M.G.L c. 47, s. 57-61, security work re ires D partment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent o�•i Signature Telephone No. PERMIT FEE: $ i- • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street f Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:�� City/State/Zip: VO Phone #:' Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.ip I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.lectrical repairs or additions 1 l.(] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other _. *Any applicant that checks box #I 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 the Rains and penalties of perjury that the information provided above is true and correct. R VA 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: