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Home My WebLink AboutPermit for Wiring - Building Permit #12547 - 314 BOSTON STREET 7/23/2014 i3 Date I O�NOpThq� o? °off TOWN OF NORTH ANDOVER a o_ PERMIT FOR WIRING i BACHUS� This certifies that 9 � G .......................................................... p has permission to perform � >, ........................................................ I wiring in the building of. ......................................... a forth Andover,M Fee, .. Lic.No. . t� ELECTRICALINSPECTO Check# _ s r _ a'+A l.-oniananu�et�l�i o� ll�nl9<ulr<< II:± �° ccy cc77 Permit No. 2ePartntenl'a�.../ire ervu'ee Occupancy and I�ee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( lFC),5 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date; "? City or Town of: � � . ��,��w ,, To the MspeCtor of 1'fir 5 By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street& Number) 1. t �C��r "' ' Owner or Tenant N'V\'c'Kx Telephone No. Owner's Address QoAQQ Is this per►riit in conjunction with a building perrnit`r Yes No ❑ (Check Appropriate Box) Purpose of Building No. C [ / �p � Y " � - ... Its � Overhead Authorization -� _ t l - L LJ Existing Service C-�Ani �s � � ' No.of 11�1eter New Service Amps / Volts Overhead❑ Undgrd ❑ No,of Meters Number of Feeders acid Am pac►t Location and Nature of Proposed Electrical Work: Completion of the ollowin table may be imrled by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus (Paddle)Fans No. o Total p ) Transformers KVA No. of Luntinaire Outlets No. of Hot flubs Generators KVA Above In- [ o. o "'mergencyLighting No, of Luminaires Swimming Pool rrrd. ❑ •rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARIYIS 'No. of Zones No, of Switches No. of Gas Burners No,of Detection and Initiating Devices No. of Ranges No.of Air Cond. Tonsi No. of Alerting Devices No.of Waste Disposers heat Pump N�frn der 'Ions KW No.of Self-Contained I Totals "` Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of D ers Heating Appliances kw Security Systems: ry No,of Devices or E ulyalent No.of Water KW No,of No. of Data Wiring; Beaters Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors .Total UP.. . TelecommunicationsNfDevies.or qu v J; Y g No,of Devices,or Equivalent. o'IIIER: Attach additional detail if desired,or as required by the Inspector of Wires. Elect,rical Wor Inspections Estimated Value of io (When required by municipal policy,) Work.to Start: ' p ns to be requested in accordance-with NEC Rule 10,and.upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the lieensee.provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is iri force,and.has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify,) I certify,under the aims and enallies o er ur that the informallon on this application is tide and complete, . p p fp I Y, FIRM NAME. LIC.NO.; �) t p license turriber , Signature T LTC. NO,,. _ Licensee: � ,f .. �, .�_ .., — rter "exempt"'in the Ir ae. (f pp � (. t. .mmw..� ,�...� cw�r �„�r 'yC. ., t.�� " ►s. Tel. No.:�--�— 1 a hcable, r 3r' .�� Address: + � Alt,'rel, No.: C *Per M.G1.c. 147,s. 57-6 1, security work requires Department of Public Safety"S" License; Lic,No. �" E OWNER'S INSURANCE WAIVER; I am aware that the Licensee does riot have the liability insurance coverage no;7Yiaily required by law. I3y my signature below, I hereby waive this requirement. 1,(un the(check one ❑owner ❑owner's a gent. Owner/Agent PERMIT IBIS; $ Signature Telephone No, ' � .t Ill: 1.-uNurrurtwr.N:err uJ irru.�au4rtN.r.. a Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MAC 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information Please Print i,4gibly Nape (Ausutess/organtzation/individual): "'` cv Address: .w .` � �.. : . . City/State/zip: w C. . Are you an employer? Chec, le appropriate box: Type of project(required); 1,011 am.a employer with 4, ❑ 1 am a general contractor and I 6, ❑ New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet, t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8, Demolition working for me in any capacity, workers' comp, insurance, g. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have uxcrcised their l0. lcctrical repairs or additions '3.❑ l am a homeowner doing all work right of exemption per MGL 11,Q Plumbing repairs or additions myself. [No workers' comp, c. 152, §)(4), and we have no 12.❑ Roof repairs insurance squired,) t employees. [No workers' 110 Other camp, insurance required.) - --- .- *Any applicant that checks box#t must also fill out the notion below showing zhair workers'compensation policy information: _._w.. t liomeownara who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidmit indicating such, tcontractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy infornwtion, 1 am an employer that is providing workers'compensation insurance far my employees Below is the policy and job,sit'e information. „i Insurance Company Name: .�. - f w. Policy#or Self-ins. Lic, #: .._ 'Expiration Datc: l 1, Job Site Address: � �- I � " " 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 MG'l,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 Officer of Investigations of the DIA for insurance coverage verification. y.- fifty q nalties o er u that the information provided Bove true and correct 1 do hereb c a ,7 nda e i d e f Phone#: �` 3, 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person; Phone#: i OF MRSSA . uotAwl • etp �C 1 PNS cEN�� MPN RO � i 2729� 1 W�ST�,1 N4 .OR �CU�N °T 1