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Home My WebLink AboutWiring Permit - Building Permit - 85 BRENTWOOD CIRCLE 10/5/2015 Date... I I �OATH,+NO TOWN OF NORTH AND OVER � WIRING c p PERMIT FOR ;,88ACHU3� ® ) 9 T. .I..................................... i This certifies that ........................................ I �. .... has permission to perform ..... • .e wiring in the building of...... •••• y I orth Andover,Mass. N I a ..................................... .. .................................. Fe e:. Llc.NO. ELECTRICAL INSPECTOR I Check# I � I Commonwealth of Massachusetts Official Use Only F Permit No. Department of Fire Semces Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (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 PRWTINIATK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVL'R 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&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) 1 Purpose offluilding 6/�&V IiJe�60 _ , e� ,/ . Utility Authorization No. Existing Service Amps Volts Overhead [-1 UndgrdF] No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion qf the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminalre Outlets No. of Hot Tubs Generators KVA No.of Luminaires 12 Swimming Pool Above ❑ ❑ No—.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS lNo. 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 Tons KW` No.of Self-Contained Totals. [Np'!Ap'�K]............ ....................... Detection/Alerting Devices No.of Dishwashers Spa.ace/Area Heating KW Local❑[J Municipal 0 other Connection urit Systems:* No. of Dryers Heating Appliances KW Sec No. No.of Devices or Equivalent._ No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent_ No.Hydromassage Bathtubs No.of Motors Total 11P Telecommunications Wiring: No.of Devices or Equivalent OTHER: 14, Attach 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: ,,el— 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 D BOND D OTHER F1 (Specify:) I certify, antler the pains and penallies ofp erjuiy,that the information ation on this application is true and complete. FIRM NAME: LTC.NO.:— Licensee: Signature LTC.NO.-. ,t (Yapplicable,enter "exeinpt"in the license number line) Bus.Tel.No.: j�k),e I , Address- ib ("/A) 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)n owner D owner's agent Owner/Agent ❑ ❑ 0- 1 TelephoneNo. FEE.- $ Si2nature �e�,t The Commonwealth of Massachusetts s Department of IndlustrialAceldents r 1 Congress Street,Sz ite 100 Boston,MA 02114-2017 v9r www.mass.gov/dia 4iM Sy1 Workers'compensation insurance Affidavit:Builder$/Contractors/Electricians/Plumbexs. TO BE FILED WITH THE FEP"T'I'1NG.A-UTHOR1TY_ Please Print Le 'bl A licant Information Name(Business/Organization/lndividual): Address: City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project()required); em to ees Aill and/or part time).' 7. New construction 1.[]1 am a employer with p y 2Q 1 am a sole proprietor or partnership and have no employees Working for me in 8. Remo delh g any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[:]lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.Q 1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12[�Plumbing repairs or additions 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13%0 R66f repairs These sub-contractors have employees and have workers'comp.insurance.t 14' Other 6.[]We are a 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.] *Any applicant that cheoks b-bk4l must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•this affidavit indicating they are doing all work andthen 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. tfthe 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. Beloit/is file policy and jots site information. Insurance Company Name: Expiration Date. Policy#or Self ins.Lic.#: lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy numtber 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. X do Hereby certify under tlzepains andpenalties ofperjury that the information provided above is true and correct: Date: Signature: Phone#: official use only. Do not rprite in this area,to be completed ley 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 Phone#: Contact Person: COMMONWEALTH OF M HUSETTS BOARD W ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ELECTRICIAN 'VINCE.NT A 'ARDIZ.ZONE �W 85 BRENTWOOD CIRCLE 'S yJ 4. 'NORTH 'ANDOVER MA 01845-2001 21''228. E.: 07/31/16 79798 ;;,, .