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Home My WebLink AboutMiscellaneous - Exception (755)NO 1 0 1 I- u Date ....... :: ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. Z; z has permission to perform ........... .......... wiring in the building of -'/ ....... . ......... .......... at ........... �5- .... 0Y ....... . Nprth Andover, Mass. Fee,3,..'/.a.-...0tIc. NO. ....... ELEMICAL INSPECMR!/ Check # N Commonwealth of Massachusetts ` = Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only � Permit No. l 0 2 �;� 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 Cod (MEC , 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant t!&E Owner's Address U-145— Is C Is this permit in conjunction Purpose of Building i? -E_3 Existing Service New Service with a building permit? LJ (Check Appropriate Box) Authorization No. ((�, Amps Volts Overhead ❑ Undgrd ❑ No. of Meters 10-0 Amps LLC / UICVolts Overhead ❑ Undgrd R No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (j t 4Z,- S F A t!t G.c Cm v`, Fiou ,o,— Completion of the JollowinQ 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- ❑ rnd. rnd. Wo . of Emergency Lighting 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 Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumpNumber Totals: Tons ... ... .. .. KW ....................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW 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(L.2_ lectr'cal Work: — (When required by municipal policy.) Work to Start: 9 6 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO ERAGE: 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 for , and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE EY BONDE] OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: 8wt LIC. NO.: rt Licensee: ,4 Signature LIC. NO.: (Ifapplicabl e "exempt" in the license umber line.) ,/ B Tel. No.: Address: 1,u.S bJ�- tii V Alt. Tel. No.: 3:2&:0 S. *Per M.G.L c. 147, s. 57-61, secuil'ty work requires Department of Public Safety "S" 'cense: Lic. No. OWNER'S INSURANCE WAIVE : I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE. $ Signature Telephone No. The Commonwealth of Massachusetts qV 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): 2>4'. t- A -k k r Le,Clz_ ,L C Address: City/State/Zip: iJti( ANT 1'hone #: Aru an employer? Check the appropriate box: 1. I am a employer with (o 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of ect (required): 6. ew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 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. 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 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: LAA,y d q Q L,y t J Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: -2-5 -?,G�v,_ ?wL5s City/State/Zip: AJ() Attach a copy of the workers' compensation policy declaration p e (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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cera y under the pains and penalties of perjury that the information provided above is true and correct. Phone #: 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 #: