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Home My WebLink AboutMiscellaneous - 84 SECOND STREET 4/30/2018N_ O O J 4 (!�% P& IV Date....:G.../�. o%........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 4�v� G?tr,................................................................I...... has permission to perform .....,...; . (la -,,c- wiring in the building of................................................................................. Q J at ..... n.. l........ ..:... --. .................. . North Andover, Mass. Fee ... o..... .................. Lic. N......... ......•:......................::.......................... ELECTRICAIf.INSPE R Check # j I&'%.- 745 1V v Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. / z< z Occupancy and Fee Checked�6-001' [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: &. —((._C) City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention tolperform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes �q, No ❑ (Check Appropriate Box) Purpose of Building le;,'k-Aoyi `,�__ Utilit Authorization No. Existing Service Amps tom/ 3 Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Number of Feeders and Ampacity 1-4t ya — Location and Nature of Proposed Electrical Work: ❑ Undgrd ❑ No. of Meters Completion of the following table may be waived by the Inspector of 6Vires. 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- E]o. o Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets 16 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum N umber Tons KW No. of Self -Contained Totals Detection/Alerting Devices No. of Dishwashers ` l Space/Area Heating KW Local. E] Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KN, o. 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 if desired, or as required by the Inspector of Wires. 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 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 ❑ OTHER ❑ (Specify:) I certify, under the pams and penalties of rju7,1tat Vie zzfornzatio on this applica 'on is true azzd complete. FIRM NAME: ��: - - V e �-) LIC. NO.: Licensee:yS�:��` Signature �� LIC. NO.: (/f applicable, enter "oxen `�n e i n e number %ly'� �� l � Bus. Tel. No.:Ci7.9 � — CQ� Address: /a .`!� L-- 9 \�4S`�c I � iM O t X42-" 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. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ �- Signature Telephone No. K� i� _ �s- -:rl 7 �7 91-ta e�ll (�- O The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 "_� - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): lkCC)V Address: to City/State/Zip: d � t-/ Phone Are on an employer? Check the appropriate box: 1. I am a employer with oL 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 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. 5. ❑ 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. ❑ w construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. � 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: E v-,�A , -1, �b•c�M Policy # or Self -ins. Lic. #: C Expiration Date: Job Site Address: ` cSeec,hi Yr , City/State/Zip: / t) 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 violato . Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insuranc coverage verification. I do hereby certify and penalties of perjury that the information provided above is true and correct. 5:;, CD 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 #: