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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
kit
,s
This certifies that .................................. ... .....
has permission to perform ...........
wiring in the building of /..0 ..........................................
-/ North Andover, Mass.
at ................... V-.. ........................................... ............
Fee../.Z�:��4� Lic. No. .05�F;5�� ..............
ELEcrmcAL INSPECMR
Check# /7336
8265.
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. Zz.(,
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 Code (MECI), 527 CM 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z�-�- O
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) ` A -r--\ CX1e
Owner or Tenant a A . 0 p _ _ ��/ Telephone No.
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building (-Q_ C
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Pro osed Electrical Work:
c'(�!- n -c -� S . L<
Ye No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Completion of the following table may be vMived 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. grnd.
o. 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 Pump
7umber
Tons
KW
No. of Self -Contained
Totals:
I
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 E uivalent
No. of Water KW
No. 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 E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated ValJoIE�Iectrical Work: (When required by municipal policy.)Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCEGE: 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 covera m force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE P BOND ❑ OTHER ❑ (Specify:)
I certify, under the a. s Indpenalties of perjury, that the in ormation on this application is true and complA.
FIRM N,M i ApQ' V l Qom_ \ice--�• �. LIC. No.1 3
Licensep: �� I kizr^ Signature (-- ( LIC. NO.:
(If applicable,(e em t in the license numbee.) Bus. Tel. No .
Address: ` iiz Q 2--A q 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. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
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 LeLyibly
Name (Business/Organization/Individual): 1 ��
Address: 0EIb
City/State/Zip: �J�%Q�1 \ Phone #: (<J I %0� I
Are yo n employer? Checpropriate bog:
1. he ap
I am a employer with 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. $
Q11;11 and have no employees These sub -contractors have
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
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. ❑ New c ruction
7. remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ 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 p
information.
Insurance Company Name
workers' compensation insurance for my employees. Below is the policy and job site
omm cry
i Policy # or Self -ins. Lic. %Iz) Expiration Date:
1W Z, !\
Job Site Address: l �� City/State/Zip:N (� r
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 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 here certif under the pains and penalties of perjury that the information provided above is true and correct.
S gnatur_, �[ �,� Date: I ��
Official use only. Do not write in this area, to be comdleted 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 #: