HomeMy WebLinkAboutMiscellaneous - 797 TURNPIKE STREET 4/30/2018N)
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0209
Date .... l 1 ................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ../....:.. n s..... E e--, ..................
...................
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has permission to perform.............................................................................
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wiring in the building of ..... .........................................
at ......... . �� .......... /7. N rth Andover, Masa.
` FeeC�9v /..... Lic. No.. ....� ...... .... . . .....
EL ICAL I R
Check #
- l.OMMonwea& Official Use Only
.1JePartmertE o�,}ire Jervicee Permit No.
BOARD OF FIRE PREVENTION REGULATIONSOccupancy 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:
City or Town of:/_ fj�T-,z,, ? L To the 1 ctor of ices:
By this application the undersigned gives nonce of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner -or Tenant �>y ^�
Telephone No. ,
Owner's Address
Is this permit in conjunction with a building permit? Yes
❑ 1Va (Check Appropriate Box)
Purpose of Building Utility Authorization No. t'
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Und rd
l; ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
77
Com lelion o the ollowin 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 Above❑ In- o. o mergency ig ing
rnd. rnd. Batte Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones
No, of Switches No. of Gas Burners No. of Detection and
Initiating Devices
No. of Ranges No. of Air Cond, g onsl No. of Alerting Devices
No. of Waste Disposers Heat Pump .Number Tons ............ No. of Self container)
.......____._
of Dishwashers
o. of Dryers
o. of Water KW
Heaters
No. Hydromassage Bathtubs
OTHER:
Space/Area Heating KW
Heating Appliances KW
No. of No. o
Signs Ballasts
No. of Motors Total HP
municipal
Local
❑ CannPetinn0 Other
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
Telecommunications Wiring:
No. of Devices or Eouivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: �5-�— (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C ERA E: 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 F] OTHER [–](Specify:)
1 certify, under the pains and Ities of perjury, that the information on this application is true and complete.
FIRMNAME: Aries Electrical Service and Controls LLC
Nor and Michaud _ LIC. NO15650a
Licensee: Signatu�°^ - � _ _ __ � 3 4 5 9 4 e
(If applicable, enter "exempt Fin the license number line.) _ NO.'
Address: 290 Broadwa suite 117 Methuen ma 01844 _ Bus. Tel. No. ATE B 7 0544
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt 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 a ent.
Owner/Agent
Signature Telephone No, PERMIT FEE: $
o,
The Commonwealth of Massachusetts
i� Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_,ARIES:-�ELECTRI CAL SERVICE AND CONTROLS LLC .
Address: .290 _RgoAnwAY sTTTTF ='` 1_
City/State/Zip: MP hiiPn Ma nl R44 Phone#: 978.,687_Q5_4_4__..
Are you an employer? Check the appropriate box:
1.'�J .I am an employer with 4. ❑ I am
_ _1
a general contractor and I
® employees (full and/or part time).*
have hired the sub -contractors
2 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no er �Hc yees
These sub -contractors have
working for me in any capacity.
employees and have workers'
(No workers' comp. insurance
comp. insurance. $
required]
5.0 We are a corporation and its
3. ❑ 1 am a homeowner doing all work
officers have exercised their
myself (No workers' comp.
right of exemption perm MGL
insurance required] t
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
XX�plectrical repairs or additions
I 1. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If
the sub -contractors have employees, the- must provide their workers' 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:�'J�
Policy # or Self -ins. Lic. #: -7, ,2 3 0 Expiration Date:
Job Site Address: "7 z 1 -em aT City/State/Zi , A
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties ory that the information provided above is true and correct.
Print Name:. Normand Michaud
V I Official use only
I1n.A
Date: r% % Y!
Phone k 978 687 0544
Do not write in this area to be completed by city or town official
City or Town: Permit/license #:
Issuing Authority (circle one):
i.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #•