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HomeMy WebLinkAboutWiring Permit - Correspondence - 855 GREAT POND ROAD 5/5/2016 Date ..... ... ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ............ 88g CHU This certifies that �-j 61 vy,'o LQ Cj C',Ae-c- ...................................� ..........................V............................................ has permission to perform ...... wiring in the building of.... . . ... ....... ......................................................... at -(�. '..,�,A -... . ......... . ........... ........... North Andover,Mass. . ......... ........ ...... Fee,,.,,,, -6 --) .................Lic.No. *'ELECTRICAL ­­­­ ........ Check# l.ommonwea&of Vamachuief Official Use Only aUecc�� lvarEment o/—}ir cc77 e�eruice6 Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYP ALL INFORMATION) Date: — -� City or Town of: U '- To the Inspector of Wires: By this application the undersigne gives notice of his or her intention o perform the electrical work described below. Location(Street&Number) �.� l' ©C 0/ Owner or Tenant e y 8 y�,�(;r �,/ A, (/ k�l Telephone No. Owner's Address 3!� 7 61— r, Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building {� `5 i d em(e 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: Corn letion o the ollowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o "mergency Lighting rnd. rnd. No'" Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.o Detection and Initiatine Devices Tc No.of Ranges No.of Air Cond. ons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW _ No.oSelf-Contained Totals: " Detection/Alertinir Devices No.of Dishwashers S ace/Area Heating KW Municipal p g Local❑ Connection El Other No.of Dryers Heating Appliances KW ecur�ty ystems:* No.o Water No.of Devices or E uivalent Heaters KW No.o No.of Data Wiring: Signs Ballasts No.of Devices or E quivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiringg: No.of Devices or E uivalent �"' OTHER: '�� Attach additional detail if desired or as required by the Inspector•of Wires. Estimated Valu of Electric 1 Work: w- (When required by municipal policy.) Work to Start:UO M ( Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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 ft—BOND ❑ OTHER ❑ (Specify:) Cj 1--c 0 E. I certify,under thepains andpenalties ofperjury,that the infor»tation/on this application is true and complete. FIRM NAME: L er)G1�f l' �l LIC.NO.: Licensee: Signature LIC.NO.: (If applicable,en t r "exempt"in the license number line. Address: I Bus.Tel.No.Tel.No • r *Per M.G.L.c. 47,s. 7-61,security work requires Department of Public Safety"S"License: Alt.L'c.No..:---a 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 Signature Telephone No. PERMIT FEE. $ _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 Y rvww.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le 'bl Name (Business/Organization/lndividual): t r Address: It V P4 C City/StateJZip: ) Phone#: Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and t employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers'comp. insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9 ❑ Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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 insurance required.]t employees. 11D Roof repairs � ] [No workers' comp. insurance required.] 13.❑Other *Any applicant that checks box#1 must also tilt out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit 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-contrneters and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: U]- G f �City/State/Zi /n0 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 certi under the pains an penalties of perjury that the information provided above is true and correct. Si ature: Date: ' Phone#: - Official use only. Do not write in this area,to be completer!by city or town official City or Town: Permit/License# Issuing Authority(circle one): i. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector LG.Other Contact Person: Phone#: r OMMOI�WgL®H,OF MAS1kCHUSE:TS �omb�OF 7777777, i - ;, �LL�TRICIANS '"'I SS,ULES THE POLLaW11WG LICENSE ,I,- AS, a RAG JOURNEYMAN E LfiR I C I�AN JAiI~S M LEONARD SR' 3 ti MIrTHUEN ,;` MA a1844 541g 8� 64441