The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Correspondence - 410 GREAT POND ROAD 8/20/2014 . . .... Date....' ��.. .. [ O& 40RT#j TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8`4.1CHUg� This certifies that . ,:„a:.:. . .� €.. an. has permission to perform ... C :.�..."u..�. v .s.}... .. - v!iring in the building of.................{.. ..". .:.. ; _......................................................... . .. .. q ?t ....�...�... ..��.�...� ?........ y �.::�:...! .....��..� .............. jNorth Andover,Mass. Fee.... ..............Lic.No. . ......... ............... ELE RICAL INSPECTOR Check# Commonwealth of Massachusetts Off.lcial se OnlyPermit N Department of Fire Services 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),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: g hs//I City or Town of: NORTH ANDOVER To the Inspec'tor qr kvire's: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) If JC) L' Owner or Tenant cl 0%/ @"i q 't V, Telephone No. 6 0 3 VL 2906- Owner'sAddress -470 GrfAl- Po A, itoitA Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) .)Purpose ofBuilding AAA,-j,.s ,,1 ' F41n, La R(n i0owk Utility Authorization No. 0;' Lj f 1 -1 1 A-0`1 Existing Service 4#() Amps 110 2�2�D Volts Overhead Undgrd F❑ No. of Meters New Service - Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ainpacity Location and Nature of Proposed Electrical Work: 1!4 Rso,&-t A4yj C,U A e'0(r 0 6 e 01 Completion qfthefiollowing,f flowing table may be waived by the Ins peclor of MI-es. of Total No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. KVA No, ofLurninaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei In El 11q-0. ot Emergency Lighting grild. rrid. Battery Units No. of Receptacle Outlets 4 No. of Oil Burners FIRE ALARMS INo.of Zones No. of Switches No. of Gas Burners No. of Detection and 13 Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices To Z No. ot"Waste Disposers Heat Pump j'Np.jpPq I Tons J.KW........... No. of Self-Contained Totals: Detection/Alerting Devices F-1 Other No. ot'Dishwashers Space/Area Heating KW Local F Municipal Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No. of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydroinassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail ifdesired,or as required by the Inspector q14NI-es. LA Estimated Value of Electrical Worlu (When required by Municipal policy.) Work toStart: I 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 COver#ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [ """BOND E] OTHER 0 (Specify:) I cert�f y, under the pains andpenalties qfpeijuly'that the hijbi-ination on this al)lVication is true and cony)[ete. 0 FIRM NAME: 1q#Vqhvq'1 ro r) LIC,NO.: 2643S 6 Licensee: AIV4410'a 4 0 0 J Signature LIC.NO.: j 0'? -19? 4 Bus.Tel. No.: 177S.-2 7 3-662S 7 C 0 ,V,-e, ?A,)efn /Pi 14- 01 V 7 i) Alt.Tel.No,:921-2")3-4-0 Address: M A" *Per M.G.L c. 147,s. 57-6 1,security work requires Department of Public 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 one)[] owner El owner's a rent. Owner/Agent Signature Telephone No, PERMIT FEE: $ --3 1'1,— The Commonwealth of'Massachusetts Form �'-- _ ,Print .„,...„.„..... Delmi-trnent of'Industrial.Accidents Office of'Investigations i r 1 Congress Street, Suite 100 r t �s Boston, MA 02114-2017 wwfv.rraass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organisation/Individu yal)' .0 a °, ' _ Address: Qj 4 ... City/State/Zip: lem M 0 7 D Phone #: X �... .... 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 pn-rployees (full and/or part-time). have hired the sub-contractors 6. ❑ New cot7strtiction 2. 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 Cot-me in any capacity. employees and have workers' 9. [eolluilding addition [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l LR Plumbing repairs or additions myself, [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 1.52, §1(4), and we have no employees. [No workers' 13.0 Other comp, insurance required.] *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. +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 rvorkets'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: ,lob Site Address: City/State/Zip: Attach a coley 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 tip 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certyj)under the pains and penalties of perjury that the information provided above is trite and correct. Sirt7ature: °" .. Date: 1 Phone##: 273 ... .j wu Of 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 Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: COMMONWEALTH OF MA,aSACHIJS�TTS BOARD`OF ELECTRICIANS. ISSUES THE-FOLLOWING LICENSE AS REGt?STERED MASTER ,ELECTR:I'CIAN. 'cc a ANTHQNY T BROOKS 5 f 7 CLARIZ AVE SAt EM MA 01970 t 717 1 • 10 A o7/ t/a6 65058 .; COMMONWEALTH OF MA,SSACHUSSTTS:: BQAFtt7 0 ISSUES THE FOLLOWING`LICENSE � AS` A R'EG JOURNEYMAK>ELECTRI'CIAN �i Iz ANTHt)'NY T BROOKS !: 7 CLARK AVE ,Z W S A UE M MA 01970-1717 26435. E 07/31/76 65057