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Home My WebLink AboutMiscellaneous - 776 DALE STREET 4/30/2018Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING .Mis certifies that ......... ........ ............................. has permission to perform .... .... .................................................... wiring in the building of .............. ....... .................................. . North Andover, Mass. Fee,-� ............. Lic. No./;Zz./.' .................. ... . ........ ................................. 4-11, ~ELECTRICAL INSPECTOR Check # 4531 Official Use Only Permit No. 41n / f Occupancy & Fee Checked - BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CM// 12:00 (Please Print in ink or type all information) Date To the Ins for tf Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street &Number/� s� Owner or Tenant�� -�` Owner's Address Is this permit in conjunction with a building permit Yes ❑ No V(Check Appropriate Box) Utility Authorization No. Purpose E)dsting New Service Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Undgmd ❑ Undgmd ❑ No. of Meters _ No. of Meters INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalentYES NO = h valid proof of same to the Office YES = NO = If you have checked YES please indicate theiyp� ofOage by checking the appropriate box INSURANCE BOND = OTHER = (Please Specify) (ExplAtion Estimated Value of 1 rical orkb Work to Start a Inspection Date Resquested Rough FinalSigned / o� FIRM NundeAME rthe en �s e u2 �, LIC. NO.�/ Ligensee�� / / Signature ry/LIC. NO. a!�- /.�i/I�fj'i�/rr /�"' / Bus. Tel No. ��O ` Address s.l Ai. Tel. No. 241- L OWNER'S INSURANCE WAIVER: I am aware that the icenses does of have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ v� (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixt res Swimming Pool gmd ❑ gmd ❑ Generators . KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers SpaceVArea Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Low Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalentYES NO = h valid proof of same to the Office YES = NO = If you have checked YES please indicate theiyp� ofOage by checking the appropriate box INSURANCE BOND = OTHER = (Please Specify) (ExplAtion Estimated Value of 1 rical orkb Work to Start a Inspection Date Resquested Rough FinalSigned / o� FIRM NundeAME rthe en �s e u2 �, LIC. NO.�/ Ligensee�� / / Signature ry/LIC. NO. a!�- /.�i/I�fj'i�/rr /�"' / Bus. Tel No. ��O ` Address s.l Ai. Tel. No. 241- L OWNER'S INSURANCE WAIVER: I am aware that the icenses does of have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ v� (Signature of Owner or Agent) Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02311 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rry employees working on this job. Company name: Address City Phone # Insurance. Co. Poligy # Company name: Address City: Phone* Insurance Co. Pokv.# 11 Failure to secure coverage as required. under Section 25A or MGL 152 tan lead tordw irnpositim of criminal penalties of.afine up to $1,500,00 and/or one years' irrpnsorwxmt-as welLas_c nd,oenakwslo3 elamjd.aMDP1NDW -ORDER and afne-cfj$11l m)-aAW,- geinstme, I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / db hereby cwW mdar the pantos and penalties of perjury that the it kmUthon provided above a bre and correct Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town officiar r R City or Town Permit/ icensirg Building Dept E)Check ii immediate response is required Q Licensing Board E] Selectman's Office Contact person. Phone # D Health Department Ei Other