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HomeMy WebLinkAboutWiring Permit - Correspondence - 500 GREAT POND ROAD 10/29/2014 �M a ;cp . .......... Date............. . NOATN,� TOWN OF NORTH ANDOVER NG o�o'`�'''•`• %omp PERMIT FOR W1Ri o,�....5,}.• g �88Actlu .... 3 This certifies e tha . ........... s ;" ,erf orm . has permission top pp .................. 1� I Q d 4 - .... S Wing in the building of f„ orth Andover,Mass. P ..... { a A .......... ....... ,.at ...... ... �� f F . .. R1CAL INSPECTOR ................ Check# -= Official ljgie Only Commonwealth of Massachusetts F De Permit No.partment of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. i/07j (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code Q,50 CMR 12.00 10 / (PLEASE PRIWTININK OR TYPE ALL INFORMATION) D 4/, /4", City or Town of: NORTH ANDOVEi R To the Inspe6ol of Wires: By this application the undersigned gives notice of his or her mitenti9ij to PC form e lectrical work described below. Location(Street&Number , Owner or Tenant Nil AA (!�204 DN CZ-b Telephone No. Owner's Address Is this permit in C conjunction wit I(Id abuildingp t? Yes ❑ NoV (Check Appropriate Box) — K Purpose of Building 79 F1 Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd[I No.of Meters New Service Amps volts OverheadF] Undgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the fallowing table may be waived by thHnspector 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 Ei In ❑ N—O.—OTF mergency Ligiffing grnd. gi-nd. Battery Units No.of'Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo. of Zones No. of Switches No.of Gas Burners of ers IniDetection and tiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices jCNo.of Self-Contained Heatpump Tons IKW No. of Waste Disposers Totals: ................. ....................... Detection/Alerting Devices Municipal E] other No.of Dishwashers Space/Area Heating KW Local Connection No.of Dryers Heating Appliances IOWSecurity Systems:*No.of Devices or Equivalent No. of Water I(W No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent . ........ Telecommunications Wiring: No.Hydromassage Bathtubs No.o.of Motors Total UP No.of Devices or Equivalent OTt,HER: 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- e� Inspections to be requested in accordance with WC 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 i urance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover e is in force,and has exhibited proof o rmit issuing office. CHECK ONE: INSURANCE OTHER El (Specify:) I cerilry, under thepains Ifies !f application is true and complete. ire a 0 P ejur that il ' tfj plete* y, i the in orination on this applic L/ FIRM NAME: . 44 bec,'tt(- th Tj '-16 LIC.NO..X,�1�33 Licensee: by Signature ANC Lie.NO.: (If applicable,enter, th licens number line.) Bus.Tel.No.:-Address: -eh I'I A16 /;�p4v-4 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work rcquirks Department of Mthe Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: T 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)0 owner 0 owner's agent. Owner/Agent Signature Telephone No. .PERMIT FEE: $ The Coma ofMassachusetts Departmentoflnd'ustriglAccidde is Office oflnvestdgations 6#0 Washington,Street -Roston,MA 02111 -www.mass:gov/ctia Wo rkexs' Compensation Insurance Affidavit:Buff iers/Contract ors]Eleetrxczans/Pliimbers Ap pllieant Wormati.on Please Print LeaM 'Name(Business/organization&dividual): Address: City/Stake/Zip:_ l V 0ISY6 Phone#: q Y 0 &3 j Are an employer?C.eek theappropriate box: 'Type of p ect(required): 1. 1 am.a employer with 4. El am a general contractor and 1 6. [ ow c6nstruction F employees(full and/oxpa -time).* haveliiredthesub-contractors 7• El 2.01 am a sole proprietor or partner- listed.on the attached sheet.' ship and'lave,na.employees These sub-contractors have 8. ❑Demolition. working for mein any capacity. workers'comp.insurance. 9. ❑Building addition Wo workers' comp.insurance 5. [] we are a corporation and its 10.[!Electricalrepairs or additions required.] officers have exercised.theix 3.[r X am a homeowner doing all work right of exemption per MGL 11. (Plumbing repairs or additions m7self[No workers' comp. c.152,§1(4),andwehaveno 12,Q Roofrepairs insurancere employees.[No workers'�iced.a 13.E]Other comp,insurance required.] XAny applicant that checks box#1 must also fill out the section below showingtheir workers'compensationpolicy information. i-Homeowners who submit this affidavit indlcatingthey Ore doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheekthis box must attached as additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information. lam an employer thatisproviding workers'compensation insuranceformy employees Below isthepoliey ant joh site information. ?Insurance Company Name% Policy 4 or Self ins.Lic.ff: �J Expiration Date., f �' Job Site Address: coo _City/State/Zip: Attach a copy of the workers'comp ensationPolicy declaration page(showing the policy number and expiration date). Failure Ito secure ooverago.as requiredunder Section 25A,ofMGL o.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 statementmay be forwarded to the Office of- Investigations of'the DX A.for insurance coverage verification. ~X do hereby Bert&u ' r the pal dp nallies of perjury treat t1ae information provided a7 oY zs tr a anti eorr�eet, Signature: Date: Phone#: Official use drily. Do,not Write in this area,to be completed by city or town official: City or Town, Permit/License# Issuing Ai thority(circle one): 1.Board of Health 2.BuildingDepartment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - CoatactPexson: Phone#: x e. MW 7 � STEP"NEN 555 SALEM ST NORTH ANDOVER MA W845 3-10t% 4 Fold,Then Detach Along All Perforations COMN(©HwALT ��A�Cs��ECNu'SE�rr�: ��.I<C7�t 1 CI itN� SS1ES TFtE F#JLE OWEN INSE ul STEPf1EN M. Jl1BA I I# ` " ' 55 SItLM 'S7 1'#�1�T� 'A V1#i �4A 01845 �1 C19 07r- 1f ... . s . � z Date.... ', �.. .....G .. aor+rH oF,,,•• .,'ti TOWN OF NORTH ANDOVER a PERMIT FOR WIRING 188ACHU•y�� `� �,... { This certifies that ... .......... has permission to perform ....................... .... wiring in the building of �. s '. ...•. � ... ..•...... North Andover,Mass. at ........ ........................ ...... .... ......... ..�,. _ Fee.." Lic.No. L .� .r.... 'V�....,... I PEC . .r .. n � r� ELECTRICAL INSPECTOR 4 /i Check# pp ��/q // Official Use Only Com.�nontvealt�o�/t"Ja�aachtc�etta Y, 1 Permit No. 2epartment 013 ire Service.4 _M_ , Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 ) 5-)7 CMR 12.00 %P,!- SE fJPJ..VT JV INX OR TYPE A_ IX TOR TION bate: Cite or Town of: To the Inspector of Wires: B; 17is application the undersigris`6 gives notice of his or her intention to perform the electrical work described below. Location (Street&Number Ova ner or Tenant 110/0 Telephone Nor ' Owner's Address Is this permit in conjunction witlila building permit? Yes ❑ No ❑ (Check Appropriate Boa) Purpose of Buildina _ Utility Authorization No. Lxistina 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: p/,j a Completion of the following table may be waived b•the Inspector of Wires. moo. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. of Total �- • Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA Above In- o.o Emergency Lighting !No. of Luminaires Swimming Pool grnd. '❑ grnd. ❑ Battery Units INo. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No. of Gas Burners No.of Detection and Initiating Devices Nu. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of"Waste rite Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: .-. ...... ........................ ....................... Detection/Alerting Devices r K�7r r r tio_ of Dishwashers Space/Area xleatiltg Y, , ucal El Municipal Connection ❑ Orti�•.er KW Security Syystems: 1`!o. of Dryers Heating Appliances No.of De��ees or E uivalent I' No. of�,N'ater No. of No. of Data Wiring: kNo- Heaters kW Signs Ballasts No.of Devices or Equivalent Hydromassa e Bathtubs No.of Motors Total HP Telecommunications Equivalent g No.of Devices or E uivalent OTHER: 0/0. Attach additional detail if desired, or as required by the Inspector of Wires. 6 —sti�liated Valc e f E1ec rical�'vork: (When required by municipal policy.) %'Ork to Start:I G inspections to be requested in accordance with MEC Rule 10,and upon completion- INS LRANCE C VE AGE: 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 undo:signed certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. �'H1 Ck ONE: NSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certyj,', under the pains and penalties ofpetjury, that the information on this application is true and complete. FIRNI NANtE:14J � �'► �� LIC.NO.: Licensee: Signature C.NO.:1/7s T al plicable, enter "exenz t' in he lice se n mbe•li e.' Bus.Tel.No.. Address:,_ f / L ! Alt.Tel.No. "Per NM-G.L. c. 147, s. 57-61,security work requires Dep ent of Public Safety"S"License: Lic.No. ON,N•NER'S I.NSUP,. NCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by lay.. By my signature below,I hereby waive this requirement. 1 am the (check one)❑ owner ❑owner's agent. O.vner:,Agent PEI21IVIIT FEE: I Signature __ v Telephone No. The Commonwealth of Massachusetts ��:Prin`t,Form .Department of Industrial Accidents Office of Investigations 21 1 Congress Street, Suite 100 Boston, MA 02114-2017 ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name (Business/Organization/Individual):Lighting Retrofit Services Address:234 Ballardvale Street City/State/Zip:Wlimington, MA 01887 Phone#:978-988-7800 Are you an employer? Check the appropriate box: Type of project(required): I, ✓❑ I am a employer with 42 _ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp, insurance comp. insurance.$ required.] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no Lighting Retrofits employees. [No workers' 13.0 Other g g comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Flomeowners 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 state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Hartford Insurance Company Policy # or Self-ins. Lic. #:000350415 Expiration Date:04/13/14 �, ❑ � � . Job Site Address: � City/State/Zip: A 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 $4,500.00 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 nder the ains and alties o erjury that the in ormation provided above is true and correct. Si nature: Date: Phone# w._ 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#: s , Date .1�( '¢'. ............. TOWN OF NORTH ANDOVER aO�r• �. .• pp� a * PERMIT FOR WIRING i3 88ACHUg� i t 4 �I This certifies that � !y6H ..... ......... ..........€ has permission to perform ', r- t wiring in the building of u E ' ` it at r..h., t '.....". `...:::. n North Andover,Mass.. 11C.NO . . °..... . . •�. ELECTRICAL INSPECT Of R 1 ¢ ! Feey i-2.12 ...... ... . t� Check# j elmmonwoahli.of Mamar4udeffi Offlejal Use 0Jly Permit No. llqb� 20partment 0/-c7ifv SopvIvej Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 Qcavblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be peribrined in accordance with the Massachusetts Electrical Code(N,IEC),527 CMR 12,00 (PLEASE PRINTIN INK OR TYPE ALL I.Nfi()]?U,4 770N) Date: City or Town of: mmt- PeAdoje*_ TO 1,17e 111,Ypeclor qf*Wires: By this application the undersigned gives notice of his or her intention to perfbrrn the electrical work described below. Location(Street& Number)__ S700 (�o Owner or"Tenant My* jjA&jpfi 'Telephone No. M-72tf-10/0 Owner's Address Is tills permit ill conjunction with it building permit? Yes F-1 No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ lhidgrd El No.of Meters Nn-Y 891-vice Amps Volts Overhead Undgr(i Ej No.of Meters Number of Feeders and Amptielty Location and Nature of'Proposed Electrical Worl(- RE L0C-&'.T-C 2- Corn y2letion qf the fiollowing able inay he waived 4),the Inspector of'Wlres. No. No.of Recessed Luminaires No.of Coll.-Susp.(Paddle)Fans r of otal T ansformers KVA No.of Luminaire Outlets No.of Hot Tabs Generators KVA Above In- INO,Ot E fimerkmwcy-Li-hting rml, R No.of Luminaires Swimming Pool grud. Battet, Units a No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS jNo.of Zones N—Of Detection and No.of Switches No.of Gas Burners o. Initiating Devices ol No.of Ranges No.of Air Cond, Tonsta No.of Alerting Devices ---- - R [NAMPer RW No.of Self-Contained No.of Waste Disposers cat Pump IYRM� I........................ Detection/Alerting Devices Totals: No.ot'Dishwashers Space/Area Heating KW "cal❑ Municipal Other -connection No.of Dryers Pleating Appliances Ceti rf tv��;ystem—s: KW No.of Devices or Equivalent No.ofWater KW No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E tirva-ent Telecom to all ications Wiring: No.flydromassage Bathtubs No.of Motors Total UP No.of Devices or Equivalent OTHER: Attach additional detail ij'desired,or as required by the Inspector of Wires:- 13,stimated Value of Electrical Work: (when required by municipal policy.) Work toStart: Inspections to be requested in accordance with ME.0 Rule 10,and upon,completion, INSURANCE COVERAGF, Unless waived by the owner,no perinit for the performance of electrical work may iSSLIC unless the licensee provides proof'of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coversjW,.m in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K;--"-130ND n OTITER. 0 (Specify:) I ceillfjP,under the Calits,atidpenalfles of1mijury,that the Information an 11115 application Is true and complete. FIRM NAME, LIC.NO.: Licensee: , h M?-S ettakkev Signature JAC.NO.:EI(pItL (/fqppflvable,enter "ex I 1PI /a the U-use 1114111ber flne.) Bus.Tel. c4lo 1- 1AAP Address: Alt. rel.No.: *Per M,G.L.c' 147,s.57-6 1,security work requires Depal-tatent-ol-Public Safety 3"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by low, By my signature below,1.hereby waive this requirement. I am the(check one 0 owner 0 owner's agent. Owner/Agent Is,i'n"ll" Telephone No. LPERMIT FEE.- S /2, �y- — -_= The Commonwealth of Massachusetts Department of Industrial Accidents office of/nlrestlgations 600 Washington Street, 7`t'Floor � Jv Boston,Mass. 02111 Workers'Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors_T A- ------- —— -- —Pniicant mformationc Please—PR --le ibly name: address: city state zi phone# work site location full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction emodel i❑ I am a sole proprietor and have no one working in any capaciTy ❑Building Addition 64 -- — am an employer providing workers'compensation for my employees working on this job. corn--12any name: . . address hone insurance co. � lLl e nohcv# . -- I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed be_low who h the following workers'compensation polices: ave Om an name: address.- city: insurance co. com an name: address: CiLy. hone#: insurance co. olio # [Attach addi_ttonal sheet if necessa-ry Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as' penalties in the form of a STOP WORK ORDER and a fine of$1o0.00 a day against me. I understand that a copy of this state ax be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby rtify under the p ' s and penalties of perju7 that the information provided above is true and correct. Signature Date Print nam Phone# `• —f~s _'� official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department Elcheck if immediate response is required ❑Licensing Board OSelectmen's Office contact person: phone# OHealth Department ; `, (revised Sept.2003) ❑Other