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Home My WebLink AboutWiring Permit - Building Permit - 34 GLENORE CIRCLE 1/13/2013 a • � Date . TOWN OF NORTH ANDO PERMIT FOR VER WIRING This certifies that . ILIvngq� has permission to e � : p rform . . . . . . . . wiring in the building = t d at Fee.. `Lic. No. . �� I' . . . , N OA Andover, ass. Check# ELECTRICAL INSPE TOR Commonwealth ®f Massachusetts official Use Only Permit No. � �Department ®f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION MIT° TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: I �{ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his ox hex intention to perform the electrical work described below. Location(Street&Number) L-C 5I/V1) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) ��i i��•4� Utility Authorization No. Purpose of Building 0 - 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: ,i Completion of the following table may be waived by the Inspector of Wires No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o,o Emergency ig tmg No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switelies No.of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices . No.of Ranges Tons HeatPump 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❑ Connection Appliances KW Security Systems` Heating No.of Dryers g pp No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or 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 f Electrical Work: �yct� Ji (When required by municipal policy.) Work to Start: N K 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 cove -is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:) I cent fy, under the ains and penalties of perjury,that the information on this application is true and complete, FIRM NAME: . n t.�l LIC.NO.- FIRM Licensee: Mk,(,4 A ez '>�A.r4� Signature LIC.NO.:� Bus.Tel.No.: _ _ 9`(' (If applicable,enter "exem t"in the lic se number line.) Alt.Tel.No.• �" �-- I w5 A v *Per M.G.L c. 147,s.57-61,s curity work requires Department of Public Safety"S"License: Lic.No.- Address: � 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)[I owner ❑owner's agent. Owner/Agent Telephone No. [jPkRMITFEZ$ Rianntnre _ — P The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): \P7)1AA AA AC-'C -- Address: V,-_S bo.,- City/State/Zip: 4 6`5TOK) l��i 2� � "hone#: 9 'L._._--- Are yo�t an employer?Check the appropriate box: Type of project(required): 1. I am a employer with_� _ 4. ❑ I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.El- I am a sole proprietor or partner- listed on the attached sheet.I ❑modeling 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 required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 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. t 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 am an employer that isproviding worlrers'competisatiorz insurance for my employees. Below is tile policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: L1L6A/o 11 City/State/Zip: � ��I V�KE ✓1� �/VY 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 certif unde(r�the_pains and penalties of perjury that the information pro vided(above is true and correct. Si natur J "—""-- Date: 1 I Cy l Phone#• q � �) 5 — 0<6 6 -- 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: