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Home My WebLink AboutWiring permit - Building Permit - 296 BERRY STREET 5/16/2015 4 4 r Date OF NONrp�4 ti ,,� :'• °oL TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING s8'gCHus�t i z This certifies that has permission to perform ,. � F" f m< t.... .............. ................................. wiring in the building of Rfr � ....... at Fc 3 ,North Andover, ........ .,_.... ass. Fee _................ ...Lic No." �E ...... . U� ELECTRICAL Ins Check# " p oI� C.om�nonwaalt<fi o� aeeachude Official Use Only Permit No. eGJe/narfinan�o� ifrs�erviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE' /ALL LVFORMATIO.V) Date: -f-� City or Town of: /VIdK—/�4A11jo 4W- 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&i Number) Owner or'Tenant n/ 1,Yu if Telephone No. 27 Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location a d Nature of Proposed Electrical Work: f e fYIiA/�T_� f3 Com letion of the folloiving table inay be ivaived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal Trsformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ gr ❑ ate Units ncy Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons h� No.of Self-Contained p Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection 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 Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: (J �� C Attach additional detail if desired,or as required by the Inspector of IVires. Estimated Value of Electrical Work: /4G G� (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 [BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofpetjury,that the information on this application is true and complete. FIRM NAME: IDA 1 2/7) LIC.NO.: i!�-2 2,S-67 Licensee: Signature LIC.NO.: of applicable,enter"exempt"in the license number line.] Bus.Tel.No.: Address: 2�4) Alt.Tel.No.: 4; 19 `�9� Se-3 j *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)❑owner ❑owner's agent. Owner/Agent r„-- .rTm r. m - The Commonwealth of Massachusetts Department oflndustrialAccidents tl 1 Congress Street,Suite 100 Boston,MA 02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 2ej City/State/Zip: dig" Phone#: 62133 Are you an employer?Check the appro rate box: Type of project(required): 1.❑ mployer with employees(full and/or part-time).* 7. ❑New construction 2.. am a sole proprietor or partnership and have no employees working for mein 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition (�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.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other ffi 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. #Contractors that check this box mustattached 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 most provide their workers'comp.policy number. Iam an employer that ispr6viding wor'lrers'compensation insurance for nzy employees.'Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 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 certi zder the pains nd penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone Official use only. Do not sprite 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#: COMMONWEALTH -- - . ® � OF MASSACHUSES 8(,1AR17 OR I ELE� RICjANS ISSU ,S' THE FOLLOWINGi I AS ~A .RAG JOURNEYMgNtEN„ELECTRI CSAN W DAUI C� T FORSYTH ' 20 CHARt�ES ST' PEABODY MA 01960-42 2 o E o / .l 16 340410