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Home My WebLink AboutComplete New House Wiring Commonwealth of Massachusetts official use only Department of Fire Services Permit No. t 7,< Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank 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 INJNK OR TYPE ALL)NFORMATION) Date: 0&- City &City or Town of: NORTH ANDOVER To the Inspector of res: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3ZS7 Owner or Tenant -R(,05 n Telephone No. Owner's Address ,l t.A.-L�- 2 AZfy Is this permit in conjunction with a building perm' ? Yes � No ❑ (Check Appropriate Box) Purpose of Building .9 � � Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing 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- F] o.o meLighting rnd. rnd. Satter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switelies No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No,of Air Cond. Tons TotNo.of Alerting Devices No,of Waste Disposers HeatPump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems: Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Atiach 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 thepains tend penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . % Cry n LIC.NO.: 2 y3k Licensee: -VF Signature LIC.NO.: (If applicable,enter."exemp�" 'n th license number line.) Bus.Tel.No.:-/ � Address: (:) -r)1)4- SPj e U /"z} A,1,Cy V Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safe "S"License: Lir.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 PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of IndustrialAccidenls Office of Investigations 600 Washington Street Boston,MA 02111 Uf www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: l ' City/State/Zip: 1r)"1 4 U (4(phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with S 4• El am a general contractor and I 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. F1We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. a 152,§1(4),and we have no 12,F]Roof repairs insurance ]ired.re q uemployees.[No workers' � 13.FJ Other comp.insurance required.] 'Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they a"re doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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: Vjq/ t I C, Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: L`j ��)c7 }— City/State/Zip: A_Q4J-1A 4a--'60�lk �. 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 DTA for insurance coverage verification. I do hereby cert�V and a pains andpenalties ofperjury that the information provided above is true and correct. - Si azure: Date: '?8- -2,()r L Phone#: l % f Official use only. Do not write in this area,to he 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 Cleric 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: