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Home My WebLink AboutWiring Permit - Building Permit - 150 BRENTWOOD CIRCLE 1/9/2013 Date . . �_ . TOWN OF NORTH ANDOVER PERMIT FOR WIRING Zhiel o �17 . . . . . . . . This certifies that . . . P has permission to perform 40 ®�. . . . . . . . . . . . . . . . . . . . of • • • • ' ' ' wiring in the building ' lover,Mass. at . .1� . . . ��°� � . . . . . . . . . . • ,North An Fee • . . Lic.No. . ELECTRICAL INSPE OR Check# F `I Commonwealth of Massachusetts Official Use Only Permit No. Department ®f Fire Services _ occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR MIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Coder ),527 CMR 12.0 LEASE PRINT ININK OR TYPE ALL INFORMATION) Date: (� City or Town of: NORTH ANDOVER 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)/,�'-'C7 �v\ F ?zL7C7l�� C�i t Owner or Tenant�_ AX t f:r' Ca tt i 0- L Telephone No. 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 and Nature of Proposed Electrical WorIc: L lb Completion of the following table may be waived by the Inspector of Wires. No.of TWO No.of Recessed Luminaires A( No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets 2-,0 No.of Hot Tubs Generators KVA Above In- o.o mergency ig ting No.of Luminaires � Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets Lt(D No.of oil Burners FIRE AT No. of Zones No. of Detection and No.of Switches j,o No.of Gas Burners InitiatingDevices No.of Ranges Tons No.of Air Cond. Total No.of Alerting Devices HeatFump Number Tons KW.......... No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local El Connection ec Heating Appliances Surity Systems:* No.of Dryers No.of Devices or E uivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices olr E uivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated.Value o Electrical Work: /L�1,� (When required by municipal policy.) Work to Start: ( 3 Inspections to be requested in accordance with N1EC Rule 10,and upon completion. INSURANCE CO RAGE: 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 FRrBOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . • 1 _ LIC.NO.: /Vt t�',�- Licensee: ,r'�,�C,t.�A-A M��CA,, Signature ti LIC.NO.:rG,77c�y �p (If applicable enter "exempt"in the license number Ime.) Bus.Tel.No.: 3 --—�� I Address: lr 1.U5 �r�1��a C� r ;-,� IV Alt.Tel.No.: � 3 7 *Per M.G.L c. 147,s.57-61,secu ity 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 Telephone No. PERMIT FEE: $ Ciunafiire The Commonwealth of Massachusetts Ch Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 >� wl•vw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): V ) yy L 1/VLri`t"C_� Address: P� t S v City/State/Zip: N A e Phone#: Are yg"n employer?Check the appropriate box: Type of project(required): 1. li am a employer with 4. ❑ I am a general contractor and I 6. Nmew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I 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. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I L E]Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I ane an employer Heat is providing worlrers'compeaesation insurance for ney employees. Below is the policy and job site information. Insurance Company Name: CUV Policy#or Self-ins. Lic.#: \ Expiration Date,: / Job Site Address:�6.1-C:.1�t_� 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 MGL c. 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. I do hereby certify nder the pains and penalties of perjury that the information provided above is true and correct. Signature: / u '" Date: t ( 2 ) C 3 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: