The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Building Permit - 110 BLUE RIDGE ROAD 10/8/2015 r Date.......... 4 l pV�R I of Pj NORTH 4D N O �OATH,� 7pW f®R W[R1NG O ,88ACHV`j� a� ............. ............. � _ ... e..�............. rtifies that .. ... This ce .• perform ............ ennission top ................................... haspr �:.. ` Mass. wing in the build' of °c ,North dover, An f.. ..... at .. �G INSPE � F .. 11C.No. �� •• ...... ee .a y: � LECPRICAL Check# 4h, L (fllmmonwaa&v/Mamac"alb Official Use Only 2epaptment ol 3ira Services Permit No. )d-1 15�— � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR P. ERMIT TQ PERFORM ELECTRICAL WORK All work to be performed in ac&rddnce with the Massachusetts Electrical Code(MEC),52TCMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)` Date: City or Town of: To the e Inspector of Wires: By this application the undersigned gives notice ofhis or her intention to perform the electrical work described below. Location (Street& Number) //0 Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes R No Fe-1 (Check Appropriate Box) Purpose of Building_ Utility Authorization No. Existing Service Amps __ /.--Volts OverheadF1 Undgrd 0 No.of Meters New Service Amps Overhead Undgrd No.of Meters Number of Feeders and Ampacity "J Location and Nature of Proposed Electrical Work: Completion of the fib Wowingtable maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total KVA Transformers No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above E] In- EJ o.of Emergency No.of Luminaires 3 Swimming Pool] grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of—Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. TonsTotal No.of Alerting Devices No.of Waste Diseat Pump Number Tons J.N.W........... No.of Self-Contained posers . ..... Deti!ction/Alertini!Devices I *r-1 Municlp�l 0 Other No.of Dishwashers Space/Area Heating KW Local❑El Connect No.of Dryers Heating Appliances KW Security Systems:No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Eguivalent No. Hydromassage Bathtubs Total HP ITelNo.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of PVires. 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 M BOND n OTHER [I (Specify:) I certify,under the pains and penalties of perjury,that the inform at' n on this application is true and complete. FIRM NAME: Village Electric Inc LIC.NO.:9163A Licensee: Anthony P. DelPapa Signature LIC,NO.:21861 E 4 (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.!978-2564845_ Address: PO Box 4O44Chelrnsford, MA01824 Alt.Tel.No.: *Per M.G.L.c, 147,s. 57-61,security work requires Department of Public Safety"S" License: Lic.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)01 owner El owner's agent.Owner/Agent Signature Telephone No. PERMIT FEE: $ Qe J �o ,� � � �-- I6—Lz -rs` The Commonwealth of Massachusetts Department of IndustrialAccidents d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PER-NUTTING AUTHORITY. Applicant Information Please Print Le gib Name (Business/Organization4ndividual): tof c Address: o d Q V ,I�- - City/State/Zip: 619 one#: Are you an employer?Check the appropriate box: Type of project(required): LF]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp,insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),and we have no,employees.[No workers'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 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 state 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'compensation insurance for my employees.•Below is the policy and job site information. Nsvvm Insurance Company Name: e VVC2 S r\- I C�f g 7 q Policy#or Self-ins,Lie.#: Expiration Date:_ /� Olga Job Site Address: Uff 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent'y n r tliepa'rs andpenalties erjury that the informationprovided above is true andcorrect. Si nature: 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: moo co 1, r o- . , .. An t,. ,., C TIE ' JA s,E BOX 4044 SOUTH CHELMSFO MA 01824 f 4, 9163 41 .rcn F � , E ONW 1. TT Comm MASSACk HU, S, '. AD H OF 0A , ISSUES THE FOLLOWING ANTHONY P DELPAPA ' >0 BOX 4044 0 TH C HE L MS F 0 A A 01824 0644 2186 ll:� l 271 7/ 311 P 32, �: i 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 or expired 62 4) No Workers' Compensation Insurance 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 �_