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HomeMy WebLinkAboutWiring permit - Building Permit - 80 BOSTON STREET 12/31/2013 Date.° '1h .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING CMU9� = r— � gf This certifies that has permission to perform .b 2k t, wiring in the building of....... A h 4 ............................................... t // � ( X 'mod f y f'd{�.f? F� at .... rth Andover,M s. _ Fee.:. Lic.No ',• EL CAL INSPECTOR Check# Q Lj— IL Ark-- E { <LIN\ Commonwealth of Massachusetts Official Use,Only Vill F Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE A LL INFORMATION) Date: City or Town of: NORTH ANDOVE,R 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) r:� t5-t - 'T 0,-,j Owner or Tenant '--T&�7> ri,4"Ai"T (kc N , Telephone No Owner's Address o- oi-Nca Is this permit in conjunction with a building permit? Yes (CheckA ropria4eBox) Purpose of Building Utility Authorization No. Existing Service rPc"" Amps 12c) Volts OverheadFq'-' Undgrd 0 No.of Meters New Service Amps Volts Overhead n UjidgrdF] No.of Meters Nui.nber of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.o Total ,�,O No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire,Outlets No. of Hot Tubs Generators KVA Above Fi In N-o-.-o-fEmergency Lighting No.of Luminaires 12 Swimming Pool grnd. grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS iNo. of Zones No.of Switches l No. of Gas Burners No.of Detection and Initiating Devices No.of Ranges of Air Cond. Total No Tons No.of Alerting Devices HeatFump Ap.mkeK]JoA§..........I.KW No.of Self-Contained otals: Detection/Alerting Devices No. of Waste Disposers TTU-m- 9 ta as�T-- Munic No.of Dishwashers Space/Area Heating KW Local El !pal n Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent__ No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices oi Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 1 . No.of Devices or Equivalent OTHER: Attach 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 cover go is in force,and has exhibited proof of same to the permit issuing office. CBECKONE: INSURANCE cover F] OTHER 0 (Specify:)&-me-114 I certify,under the aiiis rind penalties ofpeijurytliat the 'in ornwtlon on this application is true and complete. C- FIRM NAME: LTC.NO.:. Licensee: Signature LTC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.!- Address: 5- lkt v x-, "?,,� -S ,r 1��e7 4'e'-r-A A,( Alt.Tel.No.: *Per M.G.L c. 147, s.57-61,security work requires Department of Public Safety"S"License: Lic.No. -177eT 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: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the " notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012,The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: o Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 2 Failed Re-Inspection Required($.)❑ Inspectors Comments: • r, U Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed i Re-Inspection Required($.) ❑ Inspectors Comme Inspectors Signature: Date: FINAL INSPECTION: Pass Failed(] Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/clia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/tndividual): G �/ Ci /�� Address: City/State/Zip: G� �lzl Phone#: ���. j Z 7 0 Are you an employer?Check the appropriate box: Type of project(required): 1. ` I am a employer with 4. ❑ I am a general contractor and I 6. ❑ ew construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.1 7. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑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. c. 152,§1(4),and we have no 12.❑Roof repairs insurance .re uired employees. [No workers' required.] 13.[] Other comp.insurance required.] !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 Ric doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis 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:_ ,� Policy#or Self-ins.Lie.#: ZJ �`d¢ , ���c�( Expiration Date: " ;73. / Job Site Address:,& ,41y1)e.7i1 l- ��7� �d �``��`�`�S_?'_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 requiredunder 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. Ido hereby cep c dI;, ains andpenalties ofperjury that the information provided above is true andcorrect. Si afore: / Date: 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone##: aGOMMONWEi4LTH OF MASSIHUS '�7S ILETRICIANS I,.SSUES THE FOLLOWING L1it-ENSE RI*G15TI�>h© MASTER ELEGTRI C,I.AN �.. LAURLNO ELECTR COMPANY NC IC s� FRANK 15 MYRT. .E,'SftEET � MA ot801 5016 gHURN 32484 0 /31/tb F a i i