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Home My WebLink AboutWiring permit - Correspondence - 759 GREAT POND ROAD 11/18/2014 f i yyp i ................. p►ORT►� ' TOWN OF NORTH AN®OVER 0 9 PERMIT FOR WIRINlo G i _- ,•�88AC14Ug� This certifies that . fit. � .. �; d ... .� .......................................... has permission to perform .. . •• . .... wiring in the building of 4 .......................................... North Andover,Mass. at ......................................... Hee.. ..a N ...�i �P ""Lic. ELECTRT.O.R. . j i ;Check# Print Form Commonwea&o f/Ylamac4ujei� Official Use my cc�� Permit No. ) eC.lelvart�nent oire�eruiced BOARD OF FIRE PREVENTION REGULATIONS [Rev. 071 and Fee Checked ' j 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 IN INK OR TYPE ALL INFORMATION) Date: 11/18/14 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)759 great pond road Owner or Tenant astrid sheehan Telephone No. 6179353141 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No ®❑ (Check Appropriate Box) Purpose of Building dwelling 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: one afci receptacle for gas insert with disconnect in cellar Com letion of the.following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA — r No.of Luminaires Swimming Pool Above ❑ In- ❑ a oUnits Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets 1 No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices \ No.of Ranges No.of Air Cond. Total No.of Alerting Devices �J Tons No.of Waste Disposers Heat Pump INumber Tons KW No.of Self-Contained Totals: I Detection/Alerting Devices (�1 No.of Dishwashers Space/Area Heating KW Local ElMunicipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water Kam, 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: 300 (When required by municipal policy.) Work to Start:11/17/14 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 coverage is in force,and has exhibited proof of sa e to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjuty,that the information on is lication is true and complete. FIRM NAME: lance macinnis electric LIC.NO.:21217a Licensee: lance macinnis Signature LIC.NO.:21217a (If applicable,enter"exempt"in the license number line) / Bus.Tel.No.:5087260802 Address: 12 locust street middleton ma 01949 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Department of Pu lic 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 onej❑owner owner's agent. Owner/Agent Signature Telephone No. r PERMIT FEE: $ The Commonwealth of Massachusetts µ m mm mm Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, 1VIA 02111 `w www.Mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I,e�ibly Name (Business/Organization/Individual): lance macinnis electric Address: '12 locust street City/State/Zip: middieton ma 01949 Phone #: 5087260802 Are you an employer?Check the appropriate box: Type of project(required): 1. x I am a employer with 1 4. 0 1 am a general contractor and 1 6. New construction employees (full and/or part-time).* have hired the sub-contractors 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 workingfor me in an capacity, workers' comp. insurance. Y9. IJBuilding addition [No workers' comp. insurance 5. --- We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.E3 I am a homeowner doing all work right of exemption per MGL 1 LEJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13. _ Other *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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: the hartford 1 Policy#or Self-ins. Lic.#: 76wegpz482 1/1/15 Expiration Date: . -- 759 great_pond road norht andover rna 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 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 D for insurance coverage verification. I do hereby(fie de he pains and penalties of perjury that the information provided above is true and correct 11/17/14 Signature: Date: Phone#: 5087260802 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#: y -3' S g' F� MET Ml ELECTRICIANS ISSUES THE FOLLOWING L I CENSER AS A tECT RE'GISTEREp MASTER E, LANCE D MACINNIS ua 12 LOCUST: ST MA O� 1. 1 ` M1 DDLETON SD21 A t / t,,1/1 wo I