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HomeMy WebLinkAboutWiring Permit - Building Permit - 29 BREWSTER STREET 11/4/2014 ? � y� Date........... �.,...,$ TOW OF NORTH ANDOVER * PERMIT F �,,-..,::, :.,,• . ®R WIRING �ACHUS�� q, E This certifies that- c f�3 .... r has s Percussion to P erfo rm 6 f : ..................... ......................... r wiring g Of in the building f at . r o .. �.- Fee ° r" Andover, Mass. " is No. � �,� a EcECTRtcat Check# ...........INSPECTO j f elminonweall1i ol Mamac4aJelh Official Use Only Permit No. 2 2epaptinent 013i" Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (lea,,blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),52;CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: //le(le ( City or Town of: 41�� To the Inspector of ires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) .2.-7 dead,, - e Owner or Tenant SRII-i 1,1454 4,M1 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes R No Fe-1 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd [-1 No.of Meters New Service Amps Volts Overhead R UndgrdF1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Conip lotion of the followingtable iw be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of TotalTransformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA zi Above F-i In- ❑ I'q—o.of E mergency Lighting No.of Luminaires Swimming Pool grnd. grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump NRmber I Tons KW No.of Self-Contained No.of Waste Disposers t Pump ..................................... .. Totals: I ............ Detection/Alerting Devices T' I No.of Dishwashers Space/Area Heating KW Local El Municipal F-1 Other Connection No.of Drers Heating Appliances KW Security Systems:* stems:* y No.or Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivale t No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications W No.of Devices or Egiurly"aTen [OTHER, Attach additional detail{fdesired, 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [21 BOND F-1 OTHER R (Specify:) I certify,under the pains andpenalties ofpeijury, that the information on this 71; 1 Vi,n, is true and conil)lete. I- FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature LIC.NO.: 14963 (If applicable, enter "exempt"in the license number line.) V /Y 1 Bus.Tel.No.: 978-682-6262_ Address: 87 BELMONT ST. NORTH ANDOVER, MA01845 Alt.Tel.No.: 978-375-5734 M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety"S"*Per 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 El owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of lilassachusetts Department oflndustrialAccidents Office of lit vestigations 1 Congress Street Suite 100 Boston,.PEA 02114-241 7 w ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le ibl Business/Organization Name:DAVID ELECTRICAL CONTRACTING LLC Address:87 BELMONT ST City/State/Zip:NORTH ANDOVER, MA 01845 Phone#:978-682-6262 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with 8 employees (full and/ 1 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity: [No workers' comp.insurance required] $• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.1-1 Manufacturing no employees. [No workers' comp. insurance required]** 11 ❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' camp. insurance req.] 12. ther ELECTRICAL CONTACTING *Any applicant that checks box#1 must also fill out the section below showing their-workers'compensation policy information. *"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. l ani an employer that is providing iporlters'competisatiott insurance for•my employees .Below is the policy ill formation. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address:PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy#or Self ins. Lic. # 9353694 Expiration Date:MARCH 1, 2015 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 ofMGL 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 insuran coverage verification. I do hereby certify, a der e ' s d penalties of perjury that the information provided above is rue and correct. Si ature: Date: 1� Phone#: �' " Official use only. Do not-write in this area,to be completed by city or town official. City or Town: Permit/License if Issuing Authority(circle one): 1_Board of Health 2.Building Department 3.,City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone 9: www.mass.gov/dia .:!GOMMONW,M, iH..b A HUSETTS ISSUES THE, FOLLOWING L11ENSE ,. 1#'S A 1 'EG JOURNEYMAN ELECTkl Ci Ali'; €Q OEMN�S B BOMBARD..,Z 6© CORAL. S fw j NAW RHILL MA 01830-2168 1;3o8z 07/31/ ;6 39151 ,