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Home My WebLink AboutPermit for Wiring - Building Permit - 440 BOSTON STREET 11/23/2015 i Date„►1 l 0 r10RTN TOWN OF NORTH ANDOVER � n PERMIT FOR WIRING CHU This certifies that L r � I � W ......................................... ...... .. .............. t has pe 'rtnission to perform 6 wirin in the building .. l ...:............. .... .................................................. �� . � at .... .......... ..... ..,North Andover � .................. ,Mass. Fee..... : ...................Lie. No. ............ ELECTRICAL INSPECTOR Check# I �_ eltntnonwea&of Ma60ac4u."Ib Official Use Only Permit No. Apartment olJire—' ervicej Occupancy,and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(Ml-,"C), 527 CMR 12-00 � � , � - " , (PLEASE PRINT"IN INK OR TYPE ALL INFORMA TION) Date: � �C' City or Town of. ,),, ,,, ti h A,r �i,,((,,0(" /'' _ To the Inspector qf*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 ¢ 11 r Telephone No. "f Owner's Address Is this permit in conjunction with a building permit? Yes El No El (Cheek Appropriate Box) Purpose of Building 0 ,,f d i r�' j (,4, 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 Propose(] Electrical Work: Coniplelion of thefiolloiving table nigy,be waived by the Inspector offfires. 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 Ll In- ❑ -No.of Emergency Lighting grnd. gi-nd. Batter v Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones >;'o.of Switches No. of Gas Burners No.of Detection and Total — Initiating Devices No.of Ranges No.of Air Cond. 'rolls No.of Alerting Devices No.of Waste Disposers Heat Pump NumberI.Tons 1,!�W No.of Self-Contained T, Detection/Alerting Devices No.of Dishwashers Sace/Area Heatin 1uu1iP?l g E ElOther Connection Security No.of Dryers Heating Appliances KW y Systems.* Devices 0.of Water No. of No.of No.of D or Equivalent KW Data Wiring: Heaters Signs Ballasts No.of Devices or Equival nt No. Hydromassage Bathtubs No. of Motors Total lip Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector oI'lVires. Estimated Value of Electrical Work: (When required by municipal policy.) NVork 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 trya'), 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 [S BOND [I OTHER F1 (Specify:) L-iniDihj,1/ I certify, under the pains and penalties of'peijui- .1,, that the infin-i nation on this application is true and complete. W,( C( , i ,)( - -f 1,-1 -A c f LIC. NO.: FIRM NAME: i-'- Licensee: [:,Ckil Signature . ........... (Ifoppfleable, enter "exenipt hi the license number line.) t No.:' 'i -ess Addy i &-o (7 fcl Al 'el. No.: ense: "Per M.G.I..c. 147, s. 57-61, security work requires D'el!aurtullnt of Public Safer),"S" L.ic;::Wic.No. ONNINER'S INSURANCE WAIVER: I any aware that the 1-icensce does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I any the(check one)El owner El owner's agent. Owner/Agent S,ignature Telephone No. FEE: $ Tiie Commonwealth of Massachusetts Department of Industrial Accidents } u 11 Office of Investigations i �""'�! 600 Washington Street Boston, MA 0211.1 r' ;AV www.mass.gov/dia x Workers' Compensation Insurance Affidavit: iuilders/Contractors/Electricians/Plumbers Applicant Information Please Print LeObly Name(Business/Organizationtlndividual):_E d( _ -1, ��(;r r i CC+r I CCd (()Yl{"(` _I.If.O cj Address: _ 1 W ( } V 1'11 I �C acl City/State/Zip: Are you an employer?Check the appropriate box: Type of project(required): 1.[A I am a employer with_ q 4. [] I am a general contractor and 1 6 []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. 7. []Remodeling ship and have no employees These sub-contractors have g. C]Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'comp.insurance comp. insurance.l required.] 5. 0 We are a corporation and its 10.E Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions myself [No workers'camp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#I 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'conyrensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic,#: z> C ( I. > Expiration Date: _ Job Site Address: ' 1 i r,/, r,'`1 J --City/State/Zip: 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 hereby certify under thepains and penalties of perjury that the jnformation provided above is true and correct. Signature44 _ . __-- Date: C .. ? `( 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): L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . �. ''ate. •. 4;COMMGNWEALTH ��A/�S�AGHL�S #'S `; MMO.,t WEALTH OF�11 SS CH,l�S TT,S SOARA t3 x ` r 80ARp flF ss� E ti �v -,N ` 77 s �r�r C t 1 � ►t t c Z OURNLKMAN ELfC �2 G l � r R AS : 1 R� fiTRD' ASZ� LECRIGlAN x c� It z RT TARL fz'MOR�2 L ' o P ;A RKIlL LLCRY ALCOtyp F �� x EARL30RRtLL 1 air ' 1 +2 HAUURI� L Rb ? ` vo _ Y } g a Date '' Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license_ 3) Insurance Binder not on file o expire 4) No Workers' Compensation In e Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20,Suite 2035, North Andover, MA 01845