HomeMy WebLinkAboutWiring permit - Building Permit - 98 BEVERLY STREET A 9/8/2014 1'0�
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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wiring in the building.pf
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--' ��LEC'2ICAL IN PS ECTOR. •���.
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Permit No,
2epartment ol Jim Setwice6
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occcupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/073 (leaveblank)
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(7EQ CM 12.00
(PLEASE PRINT.IN INK OR T P ALL INFOTA TlOiV) Date:77 Ct -o
City or 'town of: 774- n o714
>b616C-� To the Inspect f fires:
By this application the undersigane gives notice fhis or her intention to erform the electrical work described below.
AI
Location(Street&Num4er) I Telephone Wd
Owner or Tenant
Owner's Address
Is this permit in conjuncts- with a building,permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts OverheadF-j Und-rdF-] No.of Meters
I
New Service Amps Volts OverheadF-1 Undcrrd ❑ No.of Meters
Number of Feeders and Ampacity J-
Location and Nature of Proposed Electrical Work.a
Coniplotion of following table may be waived by the inspector offires.
No.of Total
No. of Recessed Luminaires No.of Ceil.-Susp-(Paddle)Fans Transformers KVA
of a;
=Hot
T11 -ors KVA
No.of Luminaire Outlets No.
of Hot Tubs AD-T Generators
No,of Luminaires I Swimming Pont Units
No. of Receptacle Outlets jNo.of Oil Burners FIRE, ALARMS No. of Zones
of Detection and
No. of Switches No.of Gas Burners Initiating Devices
No. of Ranges Total No.of Alerting Devices
No.of Air Cond. Tons t,
eatPurnp Number Tons KW No.of Self—Contained
No. of Waste Disposers Totals Detection/Alerting Devices
Municipal F-1 Ot ther
Space/Area Heating I(W Local❑ Connection
No. of Dishwashers 2� Security—Systems:*Heating Appliances KIW A . alent
No. of Dryers n No.of Devices or Equi 0.)
No. of Water No. of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
're—lecommunications Wiring:
No. Hydromassage Bathtubs No, of Motors Total HP No.of Devices or Equivalent
OTHER: required by the Inspector of Fril-es,
Attach additional detail if desired,op i as
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 pen-nit 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 ge is in force,and has exhibited proof of same to the pen-nit issuing office.
CHECK ONE: INSURANCE E�/BOND 0 OTHER ❑ (Specify:) application is true and complete,
I certify, under the pains and penalties qfperjury,that the information oil this LIC.NO.:
I L�
FIRM NAME: :.-dLL)
Licensee: ature LIC.NO.:
Tel.No.:
(ff applicable, enter "exempt"in the license nnrnber litr .) s.
Address: L Alt.Tel.No..
*Per M.G. f Public "S"License; Lic.No.OWNER' I s not have the liability insurance coverage normally
required by law, By my signature below, I hereby waive this requirement. I am the(check one) F]owner ❑owner's agent,owner/AgentrPtfff FEZ
Signature Telephone41No.
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11 M �
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
mm.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): SPEED WIRE INC
Address: 1750 N FLORIDA MANGO RD SUITE #106
City/State/Zip:WEST PALM BEACH Phone #:561 254-8610
Are you an employer? Check the appropriate box: Type of project(required):
1.NO I am a employer with 10 4. 0 1 am a general contractor and 1 6. F New construction
employees (full and/or part-time)..'It have hired the sub-contractors 7. F1 Remodeling
2,0 1 am a sole proprictor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. Demolition
working for tile in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
3.0
I am a homeowner doing all work
officers have exercised their I I.[] Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.[] Roof repairs
insurance required.] t c, 152, §1(4), and we ]lave no 13A Other BURGLAR ALARM
employees, [No workers'
comp. insurance required.]
*-Any applicant that checks box#1 must also lilt out the section beloxv showing their workers'compensation policy inronnation.
I Ilorneowners 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.
Below is the polish and job site
information.
Insurance Company Name-LOCKTON COMPANIES LLC
Policy# or SeV-ins. Lic. #:C4793820A Expiration Date: 10-01-2014
Job Site Address: ALL LOCATIONS 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 MOL c, 152 can lead to the imposition of criminal penalties of a
fine Lip 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 D IA for insurance coverage verification.
I t10 hereby certi:fy r the painsayidpciialtiesofperjtirytlitittlieitifoi-iittitioiiprt)vi(ittitil)o e s trite id correct
SieriatUre: Date:
Phone#:
Official tise only. Do not write in this area,to be completed by city or town offlelat.
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
1 Commomvealth of Massachusetts '
Department of Public Safety
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