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Home My WebLink AboutWiring permit - Building Permit - 22 GARDEN STREET 10/1/2015 Date.... .. ....... �ORTI� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �' d _ lg I This certifies that ..... ..�..... ..��..�.................................. ....................................... ....... . ,. .. .� has permission to perform .... :+. °. :.......... ....... �o.............�... wrong inthe building of........ ° 3 r c North Andover Mass. at ......... ......... ......... R........ ......... ..............., Fee...,.:. �..........Lic.No. ........a.. .................................................................................... ELECTRICAL INSPECTOR i Check ItL j 6' b ✓ __ �_ i Commonwealth of Massachusetts 0 icial Use Only Permit No. Department of Fire Services 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 7 CMR 12.00 (PLEASE PRINT INNK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVE R To the insikolor Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number). Telephone No. Owner or Tenant Owner's Address Is this Permit in conjunction with a buildin hermit? Yes No ❑ (Check Appropriate Box) Purpose of Building Alt utilitr i#borization No. 2 0 ito ..... 0 Amps /J Y� Volts Overhead Undgrd F1 No.of Meters l,) 1�4. LJ: Existing Service zx� — _Z� New Service —0 Amps Ifi) /J Vb Volts Overhead R Undgrd D No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Ah r1i(-,i w &—rit-5 Completion of the followingtable may be ivalved by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers 1--'_VA No.of Luminalre Outlets No.of Hot Tubs Generators KVA Above ri In- I mergency Lighting No.of Luminaires Swimming Pool %4rnd. grnd. F1 Battery Units No.of Receptacle Outlets No.of Oil Burners FJT%ALARMS lNo, of Zones No.of Switches No.of Gas Burners of Detection and Initiating Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons No. of Waste Dis Heat Pump I Numb Tons 0.of Self-contained posers Totals ........................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑D Municipal El Other Connection urit y Systems:* No.of Dryers Heating Appliances KW Sec No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total 11P No.of Devices or Equivalent OTHER: .4tiach additional detail 1fdesired, or as required by the Inspector of Wiles. 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 MAI' nce including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [9 BOND [I OTHER F1 (Specify:) I certify, under the pains rind penalties o ei,.wy,that the information on this application is true and complete. FIRM NAME: 1b LIC.NO.: Licensee:—T-h Signature:ju LIC.NO. (If applicable,enter "exempt"in the license number line) Bus.Tel.No.- Address: OU 0) C u i?cA 01711%, 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)El owner F]owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE.- $ The Commonwealth of Massachusetts Department of lndustrialAceldents n _ - 1 Congress Street,Suite 100 C Boston,MA 02114 2017 `> www.mass.gov/dia Workers'compensation insuranceAfiidavit:Buildexs/Contxactors/llectricians/Plum err. TO BE FILED WITH TBE PERMITTING.A.UTHOMI Y. Pease Print T e 'bl A licant Information f_ Name(Business/Organization/lndividual): Address: � UU yL C y7—T ,�" � r� � Phone#: �U� City/State/Zip: v D p Are you an employer?Check the a pp ro xlafe box: Type of project(xequired): em to ees £rill and/or part time).* 7. i(OW d6nstriictlon 1,Q I m a employer with P y ( 2. I am a sole proprietor or partnership and have no employees working for mein $. modelinganycapacity.[No workers'comp.insurance required.] 9, mohtion 3.[]lam a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. Ia. PtM— bing repairs or additions 5.❑I am a general contractor and Ihave hired the sub-contractors listed on the attached sheet. 13%F]Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.❑We are a corporatign and ifs,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 checks box 41 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit•this davit 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 not(hose entit}es have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer tat is providing workers'compensation insurance for°my employees• -below is the policy and job site h information. Insurance Company Name: Expiration Date: Policy##or Self-ills.Lie.#: 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 requixed under MGL e.152,§25A is a criminal violation punishable by a fine up to$1,500.00 ies in the form of a STOP WORK and/or one-year iolato .A cop as thus statement ml as civil ay be forwarded to the Office of Inveesgat ons of the DIA for insER and a fine of np to urance a day against the violator.A copy coverage verification. pWand ' s of perjury that the information provided'ahoy is true and correct. X do lierehy certify n der the a Date: Si afore: ` Phone#: Official use only. Do not write in this area,to he completed by city or•tolvn official. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone##- Contact Person: COMMONWEALTH OF MASSACHUSETT:S ELECTRICIANS ISSUES. THE FOLLOWING LICENSE F AS A REG JOURNEYMAN ELECTRICIA TMOMAS P DOHERTY 3 WOLCOT- RD J WOBURN MA 01801 4812 �. 289o8 e 07/31/16 312697