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Home My WebLink AboutWiring Permit - Building Permit - 24 GILMAN LANE 3/23/2016 Date �.. .`.. &. .......... O�NORtH,� oar °o� TOWN OF NORTH ANDOVER * PERMIT FOR WIRING CHUg�� This certifies that f-a ; (41 a:" .................................................................... has permission to perform ---� =-'` a � j wiring in the building of.``. .at .. ... ...: � ................................North Andover,Mass. Fee ` ..............Lie.No e ............................. ................................... 99 ELECTRICAL INSPECTOR Check# �` 6 V � n Commonwealth of Massachusetts Official Use Only Department f it Services Permit No. ��J�� Occupancy and Fee Checked J BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR MIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NBC),527 CMR 12.00 (PLEASE 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) r�2 �/ 6i 14--t 4-N 4e� �✓ Owner or Tenant G-f'® / ; __ t /— 1 S Telephone No. Owner's Address S1-c vvyl Is this permit in conjunction with a building permit? Yes Ef 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 Work: Completion of the following table may be waived by the Inspector of Wires. No,of Recessed Luminaires No.of Ceil.-Sus (Paddle)Fans No.of Total p Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [� In- ❑ o.o Emergency rg trng rnd. rnd. Batter Units Units No.of Receptacle Outlets 7 No.of Oil Burners FIRE ALARMS No. of Zones No, of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices No. of Waste Disposers HeatPump Number Tons KW No.of Self-Contained p Totals: ..... ... ................... """""" Detection/AlertinR Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection uriNo.of Dryers Heating Appliances KW Sec No ofSystems:* Y No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: L-00 (When required by municipal policy.) Work to Start: ' Inspections to be requested in accordance with NIEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical worlc 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofpetptry,that he.inforn2ation on this application is true and complete. Mc FIRM NAME: ' rs /el -,'�� .NO.:/ l 7/ \ Licensee: 1,�C��,'r ,c)— � 5 1c-� Signature LTC.NO.: /E�`� (If applicable,,enter " empt"in the license nurn er line.) Bus.Tel.No.-Y26 ,26`1 2 h7 70 Address: f 2c f ✓� i"GI ��' ) 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)❑owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature �_ Telephone No. SIN- The Commonwealth of Massachusetts _ Department of IndustrialAccidents t r tl 1 Congress Street,Suite 100 Boston,MA 02114-2017 SV;V'�t www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information `. j Please Print Legibly Name(Business/OrganizatioiAndividual): �>C'1 u, i• Address: y G 6- �?/r- � City/State/Zip: C., �te � o,s4u,-& A Phone#: A� jo z Are you an employer?Check the appropriate box: Type of project(required): L C]I am.a employer with employees(full and/or part-time).' 7. rl New construction 2.[]I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ p 6.Q We are a corporation and its office have exercised their right of'exemption per MGL c, 14. Other 152,§1(4),and we have no.employees.[No workers'comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit phis 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer•that is providing ivor'iteis'compensation insurance for my employees.' Beloiv is the policy and job site information. ) Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: 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 required under MGL c. 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. I do hereby c '1 y und`eerr thepains ndpenalties ofperjury that the informationprovided above is true and correct. mature: Date: / J Phone#: Official use only. Do not write 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: M®NVVEP.LI H OF nAAS"CHUSETT°S f ELECTRICIANS ( I SSllES T?iE FOLLOWING L 1 O'FAiS► ° ! A A REG JOURNEYMAN ELECTRI C I din:; W �A STANDER 1,j ORCHARD STREET z I ,o 3� s'ti ORO `MA o1886 2-21 Og .E OT/311660 j