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HomeMy WebLinkAboutWiring Permit - Correspondence - 25 GREAT LAKE LANE 10/2/2015 Date ot..... OF NORT�y 9ti TOWN OF NORTH ANDOVER PIP_ PERMIT FOR WIRING cHu This certifies that has permission to perform .X wiring in the building of............... . ... .......... ....... .:� ................................................ at ,. e North Andover,Mass. . FeeLic.No, ;..., .......... .. �.. .................... ............ ...b ..�� L .......................................��® c� ELECTRICAL INSPECTOR Check# dd�Fi i C L (.,omnwnwealth of Mamac"M Official Use Only ®CJepart`ntent o�lire Jerviced Permit No. � `7 1 "I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfortned in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE AL NFORMATION) Date: City or Town of: A10 h Q 1V Pn0n 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) '(9 S 6 N Gf L 0 KG'C) L N Owner or Tenant T k 7 , L L Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building (40,-71 a 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: PC,C,'' Ycl Corn letion of the ollowin table ma be waived by the Inspector of fYires. otal No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Transformers KV KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E�ro.o Emergency Lighting rnd. rnd. Battery Units 4 J No.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 No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Ts KW No.of Self-Contained Totals on Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Conne mun'cpalm ❑ Otherctio No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent p No.of Water o.KW N of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lectrical Work: �J O� (When required by municipal policy.) Work to Start: 1 / ` 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 same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Da h tc,,,, 10 e e td et tz g Y, Signature ,= LIC.NO.:��k 3 211 �y[ (Ifapplicable, iter "ezer pt"in the license number lip .) -- - Bus.Tel.No.: 97e yi7• *©b� Address: &a llt✓l�E / 0 Pe'/p 1 61ea /'114' 014 k 3 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,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)n owner ❑owne agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massa chusetts Department of lndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114 2017 sJ,y t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / / Please Print Ledbly Name (Biisiness/Organization/Individual): e41VJ/'C��e lV'foL1 Pd 04 S , l Al,- Address: 19 4/t / r 6?k/C?G4-, td' 60 © r, City/State/Zip: D ,-4 Cl Phone#: �1� /� 7 Areyo an employer?Check the appropriate box: 'Type of project(required): 1. I am kt a employer with �`0: employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ t 13.[�Roof repairs • These sub-contractors have employees and have workers'comp,insurance. }��.,� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other S V1<4?.b /f✓e 152,§1(4),and we have no.employees.[No workers'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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer tlrat is providing wor'lcers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: !Jl /h C5 rN (� N9IV �l'© � Policy#or Self-ins,Lic.#: .S q We 0,5 0 / g v� o Expiration Date: 9/AV/ Job Site Address: 6-1&C�z fi k-e-1 I<e N City/State/Zip: V Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify underWw pains andpenaltte ofperjury that the information provided above ' true and correct. Signature: C✓ Date: ! Phone#: Official use only. Do not ivrite in this area,to be completed by city or toivn official.. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: :.COMMONWEALTH OF tVIA$SACHUSETTS .. I ELECTRICIANS }SSUES THE FOLLOWING L;1 CENSE AS E1 RED I-T ERED MASTER ELECTRIC IA .. { :DER{GK A GREENAWAY 'LU HERGET DR � J UNIT 5A -PERPERELL MA 01463 13 5 � ..� 21422:::R..:.: Oy/3:1 f 16 115412 ® B. COMMONWEALTH OF MA,SSACHUSETT I 64IAFi1?iD ELECI�tICIANS i 1 ISSUES THE FOLLOWING U CENSE . `.- AS A iREG .JOURNEYMAN .ELECTR I C I ANS, (z E DE RI?- A GREENAWAY N J 5 HERGE i OR ! UNIT 3A ( j SEE'{ ERELL: MA 01463 1315 1