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Home My WebLink AboutWiring Permit - Building Permit - 266 GRANVILLE LANE 1/14/2015 I Date... � .. ..L of NORrH qti of oop TOWN OF NORTH ANDOVER PERMIT FOR WIRING � o . A 88,CHU3�� f This certifies that ... has permission to perform ., ...•.. .F �......... ................................................f wiring in the building of.........:`............(...17............ .... ....... . ........... at ` �� ....... z f. �� .1 ��-C ' rth Andover,M s. �gp Fee ..............Lic.No)r .......�.............. ......................... ELECTRICAL INSPECTOR Check# ram_ _ Commonwealth Of N,/assachusettS Official Use Only A Department of Fire Servlce� PerTnitNo. 1 �r��'�' Occupancy.and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORMELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK 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. a Location(Street&Number) Owner or Tenant h w Jr Telephone No, •'��'�," flt"� ��N" Owner's Address Is this permit in conjunction with a buildinTee) rmit. Yes ❑ No (Check Appropriate Box) Purpose of Existing Se xce„�Building 6;� Amps r ;, � ,:"�l��, Utility Authorization No. t"/rl _ p / / Volts Overhead t. ` Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No,of Meters Number of Feeders and Ampacfty Location and Nature of Proposed Electrical Work: - A C '(do 1,1V11/ V"° Cam letion of the olloWn table inay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminafre Outlets No.of Hot Tubs Generators RVA No.of Luminaires Swimming Pool Above El ❑ o.o mergency ig ing rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices Heat Pum Number Tons KW No.of Self-Contained No.of Waste Disposers Totals Detection/AlertingDevices No.of Dishwashers Space/Area Heating K MunicfpalW Local❑ Connection ❑ Other No.of Dryers Heating Appliances I{ylr Security Systems:*. No.of Devices or E uivalent - No.of Water Imo' No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP "Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work:�" ) -°- (When required by municipal policy.) Work to Start: i,m Inspections to be requested in accordance with MEC Rule 10,and upon completion, tt INSURANCE COVE GE: 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 covera p,js'in force,and has exhibited proof of same to the permit issuing office. ® BOND ❑ OTHER ❑ (Specify:) certify,ONE: INSURANCErsien�ties o perlar ,that the information on this application is true and con;pl'eie. 0 �a X certi under•floe ,�' FIRM NAT11 .al I a ltca e,enter"exern t"i the I tense nuntbe Signature - Bus.Tel.No. " � Licensee: " LIC NO (,f IMP • P r ltne � Address: f,�t Ile�l F . ;�n Ii�:%�i� °�I t 4 t " Alt.Tel.No.: *Per M.G.L c. 147,s.57'61,security work requires Department ofP lic Safety"S"License: Lie.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 amt. Owner/Agent Signature Telephone No. PERMIT FEE:S ` The COmma w,earth Of assachzesetts - r &partm nt of in Acczc�ehts Office of Investigations boa lWasfiington Sheet .Boston,AIA 02111 -www.mass govlrlia Worke)r$o Compensatjou bsimancc,Affidavit: Sulldexrs/Con tractor slEl ctric �'s]Plrint m e r A )Zcant Information lly Name(Business/Orgmization/fndividual). 4 ' Address: �. � a.. j "" City/Statelzap: r " Phone�: � ��m_E� �r" �/ ,�-�m . .Are yotx an.employer?Check the approbxiate box: 'Type orproject(required): 1. Z am a employer with 4. ❑ 7 am a general,contractor and x 6. El NOW construction F haveliixedthe sub-contractors empl yees(full.and/or pa1t-t1me).* hated on the attached sheet. 7. El Remodeling 2, am.a sole proprietor orpartner- These sub-contractors have 8. [(Demolition ship and'have no employees Workers'com .insurance. ' wofidug forma in any capacity. p 9. []Building addition [No workers' comp.insurance 5. � We are a corpaxation audits 10 E(Electrical repairs or additions required.] officers have exercised their xightofexemptionperMGL l.l.��'x�b�g.repairs oradditions 3.❑ S am.a homeowner doing all.work 152,§1(`i),antlwo have no 12,�(Roofxapairs myself.jNo workers' comp. employees.[No workers' insurancexequixed.]i comp.insurancexequired.] 1� Other Mny applicant that checks box imustalso fill outthesectionbelowsliowingtheirworkers'compensationpol4cyinformation. i'Homeowners who submit this affidavit indlcatingthey R4 doing aliworlc and then hire outsido contractors must submit anew affidavit indicating such, TContractors that checkthis box must attached an additional sheet showing the name of tho sub-contractors and their workers'comp.policy information. X am an employer that isproviding worlfeW campertsation insurance fora my employees: .Delow is thepolley an(l;roh site infar�rnation. .� ,�.� ct.� �,�"�r" c•�" �. � �,�"�� `' - Insurance CompanyNaraw. ;p � � � � .,, �... Policy#or SOIf ins.Mo.#: 4 ! Expiration Date: C �. ity/State/Zip: Sob Site Address: .<.. �,� � •��". �"�/ '�� " n�� ' Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). P'aiiure to secure coverage as xequixed.under Section 25A of MGL a.152 can lead to the imposition of criminal penalties of a fino up to$1,500.00 and/or one-year imprisonment,as well as civil:penalties in the forte.of a STOP WORK ORDER and a fins of-up to$250.00 a day against tho violator. Be advised that a copy of this statement may be forwarded to the OfCco-of Investigations of the DrA for insurance coverage verification, aXtzes of p ,X y f P a ,µ µeorreet X rto here-by cer't�zx z, `N t7aepains an en er'ur tXtat t7te zn orrnatzon pro a ove is zze Date. r Si ature; r , ,. Phone#; Official use only. Do not write ira ill's area,to be comPleted by City or�town Official city or'Towxz: Permit/License if Issuing.Authority(circle one): I.Board of Health 2.Building Department 3.City/Tawo Clerk4.Electrical Inspector 5.P'lumbingxnspeetox 6.Other Contact Person: Phone#: COMMONWEALTH iOF MASSACGi�SETTS R��yy ® .. B AR.5. LEClRI0ANS ISSUES. THE FOLLOWING L10EF!Sk AS ' A REG JOURNEYMAN=.ELECTRI C�I;fl ,� J RQER`f J RUGG I ER*0 34 H I Ght,*W91) AUE MA 01906 3333 <... :. 37758 .E 07/3 / 6 45;1R :COMMONWEALTH OF MA SACFi&SET'1,5.;.} ® ® m ® ELECTRICIANS ISSUES �HE. fOLLOWING :ICE 15 REGISTERED MASFRLECTR:Ir OKX.,AUGGIFRO ELEC'1R!C iz ROBERT J .RUGGIERQ 34 HI.GHLlVP1D AVE �,At1Gt15 MA 01906 33�3 18358 A.. oj/ 1116 451;'9