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Home My WebLink AboutMiscellaneous - 98 Kingston Street--S) v Date ..1.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING rl I C'k 64 1 1 . ....................................................... This certifies that........................... ..... ...... . ........... 4"..aAr.-A ...................................................... has permission to perform ... ......... wiring'n the uilding of ................ ... M . .... .... .... ............................................................ at ....... ...................... No Andover, Mass. FeeLic. No. ........ t .......... ................................. ELECTRICAL brSPECTOR Check # lot r� �L�--7 (f1mmontuea& of MaBdachuAetb Official Use Only Permit No. ' 144 Z— 1 =1JePartmen� o��}ire Jerviced , Occupancy and Fee Checked r` BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07 (leave blank)' APPUCATT ON FOR PERMIT TO PERFORM ELECT , CAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (IvfEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � l City or gown of: s -. To the Inspector of Wires: By this application the undersib ed ives notice of his or her intention to perform the electrical work described below. Location (Street & Number) K\' t Sian A — Owner or Tenant i n A &-17,' Owner's AddYess N KC AMC,4 Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building Telephone No, No V (Check Appropriate Boz) Utility Authorization No, Existing Service tv�'t Amps -d6J/ ' y Volts Overhead ❑ Undgrd 12"No. of Meters 1 New Service i py Amps Volts Overhead ❑ Undgrdt� No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �(yuty� V., - Com lesion of the followin !able m be waived} b y t6 No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans N°' of Total Transformers KVA No. of Luminaire Outlets No, of Hot Tubs Generators KVA No, of Luminaires Swimming Pool Above ❑ In- ❑ o. o Emergency ig trng rnd, rnd. Battery 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, Tonal No, of Alerting Devices No. of Waste Disposers. Heat Pump Number Tons KW ;No, ofSelf-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local EJM°nicipal ❑Other of Dryers Heating Appliances KW @nnectionNo. Security Sems:* No, of Water No. of No. of No. of evices or Equivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP IT elecommunications !airing: No. of Devices or Equivalent OTHER• 1GJt21 !%t(1Ck `ice Io CGL e.i./�qc, 1>PLI,,Pitlu��iPbiNA�IpinP G�= Attach additional detail jf o- ";red, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: --7 Inspections to be requested in accordance with MEC Rule 10, and upon completion, INSURANCE COV RAGE: 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 cove be is in force, and has e�hibited proof of same to the permit issuing office, CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofpe ury, that the information. on this application is true and complete. FIRM NAME:. I ► I c"Q ( A , G( e 11c LIC. NO.:' D � Licensee: C ( SignatureNil LIC. NO. (Ijapplable, erse 'empt " in thice1nse number line) scBus, Tel. No,: Alt, Tel. No.:�3dolt *Per M.G.L. c, 147, s. 57-61,.security work requires Department of Public Safety "S" License: Lic. No, OW'NER'S INSURANCE .WAIVER. I am aware that the Licensee does not have the liability insurance coverage required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ ov,ner's Owner/Agent Signature Telephone No, PERMIT FEE; S R t C� t 0 C� t The Commonwealth of Massachusetts . Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 .�` www.mass.gov/dia / Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibly 'c�nc��e Name (Business/Organizaption/Individual): i Face.tt< letta,caL Address: 1 ��`�(•L7®!1� L °� City/State/Zip: O V*hone #: Are yo n employer? Check the appropriate box: 1. I ala employer with _. f9 ._employees (full and/or part-time). 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 6. ❑ 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): 7. ❑ New construction 8. � Remodeling 9. ❑ Demolition 10 [] Building addition 11. Electrical repairs or additions 12. F] Plumbing repairs or additions 13.E] Roof repairs 14.0 Other *Any applicant that checks box #1 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 state whether or not those entities have employees. If the sub -contractors have employees,'tliey must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees.' Below is thepoli and j, site information. �t� t q��, � Li l t ..�. ct�QAC�. ,^� � � s^i• Qe : �� , ""1rs�s Insurance Company Name: ` r� Policy # or Self -ins. Lic. #: 7 Expiration Date: Job Site Address: I 1A �T City/State/Zip:�rQ E• fP� PA, 18 15 Attach a copy of the workers' compensation policy declaration page (showing the policy numberland expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify Veder the^ns and pepalties of per jury that the information provided above is true and correct. 4 t. 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 J J