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Home My WebLink AboutWiring permit - Building Permit - 114 BERRY STREET 7/16/2015 li I I `I f Date.. ..... • I "aOR 9� om TOWN OF NORTH ANDOVE R I '. * PERMIT FOR WIRING This certifies that - 1 .......... ................................................... has permission to perform wiring in the building 1..S .. , ...........9............ ... ..... .. I at ....... ... ...... ... . .........>No ndover,Mass. Fee..... ..............LLc.No.�, /�� ELECTRICAL INSPECTOR Check# Official Use Only Commonwealth of Massachusetts Permit No. Department of Fire Services 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(NE 527CMR12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 7 al,> ,� City or Town of. NORTH ANDOVER To the lnspec6 of Wires: B this application the undersigned gives notice of his or her intention to perform the electrical work described below. y / q Location(Street&Number) j_ Owner or Tenant J',t L Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes F1 No PT"" (Check Appropriate Box) Purpose of Building Utility Authorization No. 9 1/. Existing Service 2L�.— Amps iA ,(V Volts OverheadF] Undgrd[Z],' ........No.of Meters New Service — Amps Volts OverheadF] Undgrd [I No.of Meters Nuinber of Feeders and Arnpacity Location and Nature of Proposed Electrical Work- Wc �',,e/,,& j- J;0n4-(-1 7L 1/1 1 1 (1 d r gw V , Completion of the following tab ld may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Cefl.-Susp.(Paddle)Fans No.of Total Transformers ICVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above n In N—O.—OTEmergency Lighting No. of Luminaires Swimming Pool arnd. grnd. Battery Units No. of Receptacle Outlets No.of Oil Burners F=ALARMS JNo, of Zones of Detection and No. of Switches No. of Gas Burners No. Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Heat Pump Tons Self-Contained 9M No.of No. of Waste Disposers Tot Detection/Alerting Devices Municipal El other No. of Dishwashers Space/Area Heating KW Local❑El Connection No. of Dryers Heating Appliances 111W Security Systems:* No.of Devices or Equivalent.. of Water KW No.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices or Equivalent Telecommunications Wiring. z No.Hydromassage Bathtubs No.of Motors Total IV No.of Devices or Equivalent OTHER: ��j Aliach additional detail if desired,or as required by the Inspector of Wires. 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 coverpgo is in force,and has exhibited proof of same to the permit issuing office. CBECE.ONE: INSURANCE [J'/BOND 0 OTHER [I (Specify:) I cerilry, un der the epains an dpeq allies ofp ejwy,th at th e information on this is application is true an d complete, LIC.NO.: A FIRM NAME: -'�)LIC.NO.: Licensee: Signature (If applicable, enter "exetnpt"in the license number line.) ,.,jM-/Bus.Tel.No.- Alt.Tel.No.: Address: LkeveA,(' A, *Per M.G.Le. 147,s.57-6 1,security work reqdires 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)[I owner El owner's agent. Owner/Agent Signature Telephone No. �ERMXT FEE.- $ The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 �, •a°l�. d _ F Boston,MA 02114 2017 Vqr www.mass.gov/dia 4.M 5V1 Workers'Compensation.insurance Affidavit:Builders/Contxactors/Electricians/l'lum exs. TO BE li'ILED WITH THE pERMMTT)VG AUTj(OIJTY. -Please Print Le 'bl A ''licant Infor oration Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: —}-.— --- Aro you an employer?Checl[the appropriate box: Type o£project( eclnired); to (full and/or part time). 7. ❑Thew construction L0 I am a employer with ern P yees( 2. ( I ain a sole proprietor or partnership and have no employees tozking forme in $. Remodelibg any capacity.[No workers'comp,insurance required.] 9, ❑Demolition 3.[]1 am a homeowner doing all work myself[No workers'comp.ursurance required.]t 10[1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1l.[]Electrical ensure that all contractors either have workers'compensation insurance or are sole repairs or additions proprietors with no employees. l2 ;-a Z'l,U" bing repairs or additions 5.L]l am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]1 Fj Ro6frepairs These sub-contractors have employees and have workers'comp.insurance.t ]d q Other 6.❑We area corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers comp.insurance required.] ,P y applicant that cheok§I I.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 pot those pntities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer"that is providing Worker, compensation insurance for nay employees. Below is the policy andyo7r Site information. Insurance Company Name: Expiration Dpte: Policy#or Self£ins.Lic.#: Job Site Address: City/State/Zip: Attach a copy of the workers' compelisation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e.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. f p e and,correct X do hereby certify urztl r"thepains an enalties ofperjury that the in Ormatzon provided above is true . d..:.�• � �� l ��t� a,��:z Date, Signature: Phone#: Official use only. Do not write in this area,to he completed by city Or town Official. City or Town: # Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.lJ+lectrical Inspector 5.Plumbing Spector 6.Other Phone#• Contact Person: ;COMMONW>f"ALTH OF MASSACHUSf*TTS ... BOARD 0� ; ELECTRICIANS ISSUES THEFOLLOWING LICENSE AS REGISTERED MASTERLECTRICI`AN ' i' JgSlH P G I BBONS Z -- W ju 35 LANDCASTER COU>vTY ]?D '' 4 UNIT 'A HARVARD MA 01451-1143 1 2 6 :A 07/3_a/16 ..; 61202 .. i