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Home My WebLink AboutWiring Permit - Building Permit - 299 BLUE RIDGE ROAD 1/22/2014 1 Date.......................................... �aOpT„� TOWN OF NORTH ANDOVER , .. PERMIT FOR WIRING 88'�CHUs�t This certifies thaw, . .' ....................................... .... 6 has permission to perform � �� ... t wiring in the building-of.... �� ...................... at .... .............. .. rth An Mass. Fee. Lic.No� � ��: ..�....... ......... ,................. .......... ............................. ..........ELECTRICALINSPECTOR Check# e� <L11\ Commonwealth ®f Massachusetts Official Use Only Permit No. IZAA Department of Fire Sem"ces 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(MSC),527 CMR 12-00 (PLEASE MWTININK OR TYPE ALL INFORMATION) Date: Cityion the undersigned gives notice of h or Town of: NORTH ANDOVER To the Inspector of ices: By this applicat o perform the electrical work described below. is ,her mtenti, n top Location(Street&Num er)_ P-,z 'wic Owner or Tenant L,4 NJ C-4�.v 0 A,J Telephone No. Owner's Address Is this permit in.conjunction with a buildin permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service,406 Amps )JO /,)-YO Volts OverheadF] Undgrd D No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: &,pt 0 6 5p,cX o9 -C C-0 Ll I P 0 f able may waived by the res. Completion L ?Inspector of Wires. No.of Total No.of Recessed Luminaires No.of CellSusp.(Paddle)Fans Transformers KVA KVA No.of Luminaire Outlets No.of Hot Tubs Generators Above F1 n- o.of mergency ig ting No.of Luminaires Swimming Pool grnd. grnd. Battery Units Receptacle Outlets No.of Oil Burners ALARMS No. of Zones No.of Recept Na.of—Detection a,nd No.of SwitchesNo.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices Heatpump JKW of Self- ontained Fpum No.of Waste Disposers Totalst TN Detection/Alertin Devices Munic' No.of Dishwashers Space/Area Heating KW LocalConnection'P r ' n Othe Heating Appliances 111.W Security—Systepe, - No.of Dryers No.of Devices or Eguivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent.— Telecommunications wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6 66, (When required by municipal policy.) completion. Work to Start: )'t)d '14Y Inspections to be requested in accordance with NIEC Rule 10,and upon co, 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: INSLT-PANCE'ffl BOND [I OTHERF] (Specify:) I certify,tinder i1i e P a ins an dp en allies ofp ejury,that the zn o-rination on tills application is true and complete. FIRM NAME: C,J-'g- LIC.NO.: Licensee: , ----- LTC.NO.:natdre-, 3- I- 2 —. (If applicable,enter "gxempt"in the It e �e nu e r Z, 4 >,q -el t Alt.Tel.No. Address: 6, oulCt4. ./ Bus,Tel.No.- & *Per M.G.L c. 147,s,57-61,security work requires Department of Public Safety S" icense. Lic.No.: i I am aware that the Licensee does not have the liability insurance coverage normally OWNER'S INSURANCE WAIVER: ❑ required by law. By my signature below,I hereby waive this requirement. I am the(check one)[]owner F1 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 4 >� www.mass.gov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly r- Name (Business/Organizatidn/Individual): v A PIE-5 KO U^/6-UU. Address: �r L d W E i L. P9) City/State/Zip: i ), PFAqzi-we 'A l 2?6 y Phone#: 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2,L'� -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• ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10 f lectrical repairs or additions 3.A I am a homeowner doing all work right of exemption per MGL l l.❑Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] employees. [No workers' comp,insurance required.] 13.❑Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site !formation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: )b Site Address: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a no upto$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Cup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct. igna rttf e �� C (_ --'Z�- --._ Date: -lone#: )el ? 6 3 J )CL 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: OMMONWEALTH OF MAaSSACHU khT i` .. BOA p F ELE. IRICIANS ( ISSUES THE `iFOLLOWI. DENSE AS A RED JOURNEYMAN ELECTRICIAN.j � IAMJ S S KOUYOUMJ TAN �'. 65 LOW L.L...Rp' i N4RTH READING M,A; 01864 16335 C ` 51619 07/31/16' 27440 C