HomeMy WebLinkAboutMiscellaneous - 767 GREAT POND ROAD 4/30/2018N
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that�..`,�5 ��%`..,
has permission to perform .a�.�z...S+.......
wiring in the building of .............. .' . C�.........................................
at. �P....f 2% ......
... North Andover, Mass.
��!! 4� ............... .
Fee ./'.!!'. Lic. No. 5 ! gq�
�l INSPHCTQ
Check #
'
10453 -
2012 Massachusetts EIectrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions 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 accepted by an Inspector of Wires appointed pursuant to M. 01 c. 166, § 32, an
electrical permit shall be issued to the person, firm or -corporation stated on the peamit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shallbe limited as to the time of -ongoing coAuction.activity; and maybe deemed_bythe,Insp.ector_of_Wires abandoned-and-invalid.ifbe—.
or she has determined 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 job;growth and long-term economic recovery and the Pon -nit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain -permits and licenses concemingthe 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 effect or existence" during the qualifying period beginning on August 15, 2008_and extending -through August 15, 2012.
Aide S —Perml ate Closed: ^ �--'s Note: Reapply for new perm
❑ Permit Extension Act — Permit/Date Closed: "�
C
J , 1
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official
Use Only
Permit No.(>
Occupancy 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 ININK OR TYPE ALL R&ORMATIOA9 Date: / / _ 7 —
City or Town_ of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice off his or her intention to perform th electrical work described below.
Location (Street & Number) 4 7 4fWal al / �ft a
Owner or Tenant %".G i fte -f 16 Telephone No.
Owner's Address �niyy�
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service _4a v Amps 12j2/_ --A W/Volts
New Service Amps / Volts
Number of Feeders and.Ampacity
Overhead [Z Undgrd J# No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work: ATe Lo 14 rn 16�1IV V. / W OF q
Cam tion ofthe Alowinz table may be waived by the Inspector of Wires.
Recessed ed T uminai
No. of __�- ss _ _,�. ._re
f n 1 S . ) r
No. o. a ei.. �i.sp. (1'audle� sans
No. of Total
Transformers KVA
No, of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In '171
nd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of 0111 B10-Mer117
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No..of Detection and
Initiating Devices
No. of Ranges
No. of Air Condi. Total
Tons
No. of Alerting Devices .
No. of Waste Disposers
Heat Pump I Number
Totals:
I Tons
KW
....-..........`....
No. of Self -Contained
Deteetion/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Connectioon echo ❑Other
Cn
No. of Dryers
Heating Appliances
g pp Kms'
Security Systems:*
No. of Devices or Equivalent
No. of Water Imo'
. Heaters
No. of No. of
Signs Ballasts .
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of EIectrical Work: (When required by municipal policy.)
Work to Start:/ / . 7 _ / / 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 [OND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: t LIC. NO.:
Licensee: /? �j/y! ,5 aSignature d LIC. NO.:
(If applicable, enter "exempt " in the license number line) Bus. Tel. No.• I�p 4S► " 2
Address: OZI-iy-� A e. �i� C),46, zw g / 9 Alt. Tel. No.:
*Per M.G.L C. 147, s. 57-61, security work requires Department of Public Safety "S" License: , Lic. 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/AaPnt
The Cormmnta ealth of Afassaehusetts
Department ofI.ndustrkd Accidents
L
Office ofdnvestigafiofts
600 Waykington Street
.�>;
{, j, Boston, MA 02111
www-Yzatrss gov1dia .
Yorkers' Compensation Ins4rance Affidavit: Builders/Contractors&lectricians/Plumbers
Wicant Ynfnrmnf:nn
' •+tee. 1 Il ilF� LC"!I!!
Name (Business/Organization/Individual),.
Address:
City/State/Zip:
Phare
re you an employer? Cheek.the appropriate -box: '
❑ T am'a employer
m to er with
p Y
-part-time),*
F2.
4, ❑ I am a general contractor and I'J
Type of prOject (required):
employees (full and/or
❑ I am.asole
have hired the sub -contractors
6. ❑ New ooristruction
proprietor or partner-
: ship and. have no employees
listed on the attached sheet, #
These su&contractors have
'
7• ❑ Remodeling
$. [J Demolition
working-. for me•.in�any capacity,
[No workers',com ; Jnsurance� ,
p
�`
iwoikers'. comp. insurance.
5. ❑ We ae'a. corpSrafion and its
9. ❑ Building addition
required.]
3. ❑ T din a homeowner doing
�
officers have exercised their
10- El -Electrical repairs or additions
all work
myself. [No•workers' comp.
right of exemption per MGL
c, 1.52, § 1(4); and we have no
11.[] Plumbing repairs or additions
insurance•re -required.] t
q ]
.employees. [7`Io workers'
12.❑ Roof repairs
comp. insurancerequired.]
Jg ❑Other
°Any applicant that checks bob# l must also fill out the section below showing their workers' bompensation policy information.
t Homeowners who submit this affidavit indjcating they yz doing
-- -w
all an [hen hire outside contractors must submit a new affidavit indicating such.
muy
ZCon4actors that eheclr this box ►nustettached an additional shs>Ytstiowijag i_he rsaie of the sub•con6actor grid their tier:as' cerip.
e pinyert§at is- 1!k'�sera
Folieirfnr; adoa,
seraraefof'yinformation*es. Below is tise
policy rand job shle
Insurance Company
Policy # or Self -ins. Lie.
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers', cotnpensafion policy ciecEara;tion page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MC3L c. 152 can Iead to the imposition of criminal penalties of a -
fine up to,$ "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 maybe forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
I do hereby certify under the pains rand penalties of perjury that the inforrgcatiotz pro vitled above is true and correct
3ienature:•
Date:
Phone 4:
Fkh
only. Do not wr*Ye' Eras a:ea, to be camPl9tedby city ar tRWh official
n:-' ority (circle one)a,; Health 2. Sultding Department 3. City/Town -Clerk 4. Electrical Inspector 5. Plumbing inspector
Contact Person: Phone
W 2176 Datt/..?... .....
V ORTII
&ORTH
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TOWN OF NORTH ANDOVER
Cr
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PERMIT FOR WIRING
8
ui
This certifies that .......................................................
has permission to perform ... �7� ....... .............
co
wiring in the building,,of cm
............ ....................................................... ED
CU
a& .... ................................ . North Andover, Mass
Fie` ................... Lic. No . ............. ............................................................... INSP ECTOR
ELECTRICAL
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
e; of 4t (10mmunwalt4 of Assoac4usei#» office use only
Department of Public Safety r
Permit No.
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Occupancy &Fee Checked
3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
I All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 / �g f�
(PLEASE PRINT IN INK OR�TYPE ALL INFORMATION) Date__ ZZ— g^ [ /J
City or Town of IV V Il ! y- G
The undersigned applies or a permit to perform the electrical work
Location (Street & I
Owner or Tenant
Owner's Address
.To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes U No (Check Appropriate Box)
Purpose of Building F10"Mic Ly Utility Authorization No.
Ei4ting Service Amps / Volts Overhead. El Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ Nb.� of Meters
Number of Feeders and Ampacity ��pp ��/� //�� pp� /� .. i r n P
Location and Nature of Proposed Electrical Work f..,t� l) A _IV G 1!V r 0 k0 / y A C E ®Z (_ (g n)
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws
1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YESJ0 NO ❑ 1 have submitted valid proof
of same to this office. YES NO ❑
If you have checked YES, lease indicate the type of coverage by checking the appropriate box.
INSURANCE PBOND ❑OTHER❑ (Please Specify)
/_0
Estimated Value of Electrical Work $ Sew'mi (Expiration Date)
Work to Start L L ✓ C' ` C� Inspection Date Requested: Rough Final I Z 1 `!'
Signed under the penalties of perjury:
FIRM N,
.Licensee
Address
LIC. NO. I
SS 09
UC. NO.
No. �9
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts
.General Laws. and that my signature on this permit aonlication waives this requirement. Owner" Agent (Please cheek one)
rKImAt, iaAxYL�.,4f G 8:5 -2, Z 50
TOTAL
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers KVA
Above In -
No. of Lighting Fixtures
Swimming Pool gmd. ❑ gmd. ❑
Generators KVA
No. of Emergency Lig ting
No. of Receptacle Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
No' of Ran esNo.
of Air Conditioners Ton
Initiating Devices
No. of Sounding Devices_
No. Disposals
Heat Totao
No.
of
of .Pum Tons KW
No. of Self Contained
Detection/Sounding Devices.
No. of Dishwashers
Space/Area Heating KW
Municipal
❑Other
No. of Dryers
Heatin Devices KW
Local❑� Connection
No. o No. o
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws
1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YESJ0 NO ❑ 1 have submitted valid proof
of same to this office. YES NO ❑
If you have checked YES, lease indicate the type of coverage by checking the appropriate box.
INSURANCE PBOND ❑OTHER❑ (Please Specify)
/_0
Estimated Value of Electrical Work $ Sew'mi (Expiration Date)
Work to Start L L ✓ C' ` C� Inspection Date Requested: Rough Final I Z 1 `!'
Signed under the penalties of perjury:
FIRM N,
.Licensee
Address
LIC. NO. I
SS 09
UC. NO.
No. �9
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts
.General Laws. and that my signature on this permit aonlication waives this requirement. Owner" Agent (Please cheek one)
rKImAt, iaAxYL�.,4f G 8:5 -2, Z 50