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HomeMy WebLinkAboutWiring permit - Correspondence - 440 GREAT POND ROAD 3/28/2012 Date......�.. ` •/„�.. 44 kt NORD N ,h TOWN OF NORTH ANDOVER r:t`�`'-~�••°°� PERMIT F OR WIRING 83 CH x r*rr ................................ This certifies that ........ has permission to perform .... . e building of... .... .� .. ®....d........................................... ............ Mass. r . wiring the ....... ................�orth Andover 6 at.... ... �� .. INS orib ..... Lic.No.............. BL`�crR iCAL INSPER Fee...... ..... [t °S Check # `v 0741 Eq 4 s a Commonwealth of Massachusetts official Use Only a - Department of Fire Services Permit No. �r 0-7 l ecked BOARD OF FIRE PREVENTION REGULATIONS 1[RevOcc. y�?�yan(leaaeeChve 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 (PLEASEPRWT.ININK OR TYPEALL MFO"ATION) Date: J` Z 'F — I ',�— City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned rues notice of his or her In on o to 'rfprm the electrical work described below. Location(Street&Number) L y ecl r©t1 ID .1 C _ Owner or Tenant Telephone No.��" `_ Owner's Address Ga'S / t f f� I Is this permit in conjunct' with a building permit? Yes F, No ❑ (Check Appropriate Box) Purpose of Building _ fly Utility Authorization No. Existing Service6O0 Amps / / olts°�I +Overhead❑ Undgrdin,, No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nat re of Profosed Electrical Work: v Completion qfthefiollow—ing table m be waived b the Inspector o 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 No,of Luminaires Swimming Pool Abov=znr ❑ o.o mergency ig mg rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No,of Switches No.of Gas Burners No.ofDti Detection ng anIni es No,of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number, Tons ' KW No.of Self-Contained Totals: """""""""""""""""""""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ other Connection No.of Dryers Heating Appliances Tom' Security Systems:*. No.of Water No,ofDevices orE uivalent Heaters KW No.of Ballasts as Data Wiring: Si ns Ballasts No.of Devices orEquivalent 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:'.) 2% — ..-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 covgKge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE U BOND ❑ OTHER ❑ (Specify:) I certify,under the pains_and penalties ofperjUly,that the hifol-mation on this application is true and cor p�ete. FIRM NAME: j n-s /� r I v'i c'i e LTC.NO.: 11122 5-A Licensee:_ Signature " LTC.NO.: _'� (Ifapplicable,�e�teff 022 in tpe license tumbe line.) ><3us.Tel.No.: ' C�Address: ^�r eA V- C ~, e . Z r�e C?21 Alt.Tel.No.: "'Per M.G.L c. 147,s.57-61,security work requires Department ofPublio 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 a ent. Owner/Agent Signature Telephone No. PERMIT REE.$ r t _. ._ .'L1.1i-UL•(�,�..�i.�.`'V(.4��J(U,�.[�./L'�J�+.LY]I�F''/L�'R J,J.`l��•j�•vy�'/.]�j�`( f''�•� .'...yIJ.A.�V JL.(�.L�Jl91rJ.CYJ.*•�i — �tX-LiIL.L.RV-1.LJ-4\N.4.JUY�./�r..I.a.0.� ' -. _ � . • �_ • l ' - . �'�ssec�•-~C__ �+'aileft•-•� � �3.e-•xnspectzoxt�regu�'ecY'($50.Q0)�X � 3ns,�eetoxs'copwze�fs: -•-�/ /� - �'..N a w��p/�/ (9 2-.-- ,stilf'a-... L rCv .yl (�'nspeetoxsy�zgnatuxe�azo�tzaTs) � 3=1 p-13 'asset [ MINI--[ �ns�ectaxS'cori�m.enfs: (C qi ectoxs'ftlaatuze.-).oInitials) ))ate UM-UP,GRODAD.WSPACOON. 'asset'•--Z 1 Taflea--I ate-fus ectzo7��egufre ($50.00)�[ �.s�ectozs'coxnmexttsc • Cluspectoxs},Signaiyra-l.o H-Uals) Pate )WA,C.L'��OP K +ONA:6+R u D. HAM:. 'asset - [ I 'afiet�--[ -Re-luspe&z nrequixed($50.00)-f � ns,�iectoxs'eo,xn�.epfs: (�ttsectoxs°,�zgnatuxeK�oxurtzals} Data isse��.[ � �+.afted�� ). 'ate-•xnsp ectzon xec�uv:et�(�50.00)-•[ � sp ectoxe colb netts: `uS leCfoxs' `zgxtatuSe-�oxnitfa s} - Pate 0 OR TAGS ME TO 33F, +'ZG ,RI�r OUP`,AM XXPT OAT'WTF,.W THE.AR'XA TO DE WNPECT.U+D TN NOS` .A.CCENMIE+ AND.A.n INSPECT'kox 00$50100 M TO DY,CMR.GED. The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 UT www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,{ Please Print Legibly Name(Business/Organization/Individual): --Sc-Se- �� �"\ I q Address: 3 (D V'Gya y, City/State/Zip: A e J7�-U v,J �AG, 0 21; Phone#: ,r J 0 f G) �J Are you 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. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 2.Jj I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling 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 10.❑Electrical repairs or additions required.] officers have exercised their 3.El 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.❑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. i 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. X 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.Lic.#: Expiration Date: 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 requiredunder 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. X do hereby c eqt110 and thep/ains pe aloes of perjury that the information provided above is true and correct. Signature: Y ' Date: 4 2 �- Phone#: 0 9 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: