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Home My WebLink AboutWiring Permit - Building Permit - 64 BLUE RIDGE ROAD 10/15/2013 �s Date. ...• �.................. LoRTH,ti •I-®WN OF NORTH ANDOVER ,.. c PERMIT FOR WIRING a e _ x 88�lCHU r 1 ...................... This certifies that ......: .........° fN ....................... .. �` .... ,...........0........... ssion to perform has perms .•,. �r ' f ...... ...... wiring in the budding of....................... ................................. �....3. F t� �nrth _o verq, �� ...... at ... d'g ti Lic.No .... BLE CAL INSP..SPECTOR � r... Fee............` .. ......... ( Check# ji S —f 4 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services 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(h1EQ,527 CN%12.00 (PLEASE PNNTIATNK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the-undersigned iv s notice of his or her intention to perform the electrical work described below. Location(Street&Number) &06 RoVe-F le Owner or Tenant I Z Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes-T No ❑ (Check Appropriate Box) Purpose of Building Utility'Authorization No. Existing Service— Amps volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps Volts OverbeadF] Undgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 664V /7t� &6r� Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators IWA V --TEmergency Lig t Above No,o ing 7:= No. of Luminaires Swimming Pool Dve F1 In-d. its grnd. ❑ gm No. of Receptacle Outlets No.of Oil Burners FIRE ALAiiM7�SNo, of Zones No. of Switches No.of Gas 13 No.of Detection and Burgers Initiating Devices No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices al No. of Waste Disposers Rea Number Tons..........JNW........... No.of Self-Contained Detection/Alerting Devices Conne No.of Dishwashers Space/Area Heating KW Local El Mimic'tP'ion F1 Other No. of Dryers Heating Appliances KW SecNot.of uriy Systems:*vices or E guivalent De No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent lecommunications Wirin : No.Hydromassage Bathtubs No.of Motors Total HP Te No.of Devices or Equivaglent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. AiN 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 cov age is in force,and has exhibited proof of same to the permit issuing office. A , OTIJER El CHECK.ONE: INSURANCE K BOND [I (Specify:) I certify, it n der the pains and penallies ofp eijujy,that the information on this application is true and complete FIRM NAM LIC.No.: � 4 Licensee: -;,r4 Signature Y-�)Jlv, LTC.NO.: (If applicable ente "ex ill the lice nit !no) Bus.Tel.No.: VY Address: Alt.Tel.No.!72r&F!&, *Per M.G.L,c, 147,s,57-6 1,security work requires Department of Public Safety"S"License: Lie.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)n owner F]owner's agent. Owner/Agent Signature Telephone No. FEE.- $ Fl/ ❑ 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 of 2010 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 M Failed IN Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed EN Re-Inspection Required($.)❑ Inspectors Comments: ld -/7 Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts .Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ,w Name (Businoss/Organization/fndividual) ek,71 t 1?� ) i Address: „ , . �� ✓P. City/Stafie/Zip: Phony#: �x Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ lain a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. z 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. y, C]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)i employees.[No workers' l3.❑Other comp.insurance required.] *Any applicant that checks box#1 must also sill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aee doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lain an employer that is,provNing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name% Policy#or Self ins.Lic. Expiration Date: Job Site Address: 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 requiredundor Section 25A of MOL o.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. X rlo herehy ce ,to under the pal T;Y0_5, (, fpeijuiy that the information provided above' true a d correct. Si afore r Date: t" Phone#: - , �.. • 9 Official use only. Do not write in this area,to be completed by city or town ofricial: City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: TS �AA��1AiALTH CO F ' BOARD OF ; ELECTRICIANS 1 SSUES THE FOLLOW I EI ITREI CS A ?� AS A: REG: JOURNEYMAN. Nt fZ At GREGORY .A TAYLOR jU 71,' P1KE ST TE4tKSBt1RY MA 01876 2546g882 32268E 07L3V16 _,