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Home My WebLink AboutWiring Permit - Correspondence - 169 GRAY STREET 11/30/2015 i Date... �..... ......... O�NORT►�9ti TOWN OF NORTH ANDOVER PERMIT FOR WIRING y CHU This certifies that has permission to perform ...... ,.,.. ..................... wiring in the building of....... �,9 6 .s�. .:: ....................................................... 9 �� at ...... :.:.1.........� ,..... ................................North Andover,Mass. IFee....�'� ...............Lic. No ............:.. .................................................................................... _ ELEC UCALINSPECTOR Check# ---------------- i i Commonwealth of Massachusetts official Use Only Permit No. `? Department Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (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 ININK OR TYPE ALL.INFORMATION) Date: l/-- j C - I? cj/S-� 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) I C- 6 r et 1/ 6- - Owner or Tenant - l�e V. k14 6,,E e bt i1 Telephone No._ ��_ k2 -� Owner's Address cy,vim" Is this permit in conjunction with�7, building permit? Yes W No ❑ (Check Appropriate Box) (Check ,{` Utility Authorization No. Purpose of Building ]D� - 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: Poo / Completion 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 Tr nsformers KVA No.of Luminaire Outlets No.of Hot Tubs enerators KVA No. of Luminaires Swimming Pool Above ❑ In- No.of Emergency Lighting rnd. grnd. Battery Units 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 No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW SecN.o Devices or Equivalent_ No. of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent_ No.Hydromassage Bathtubs No,of Motors Total HP Telecommunications No.of Devices or E u valent OTHER: Attach additional detail 1f desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: �` tit 1, 67 v (When required by municipal policy.) Work to Start:I/- 1� C, 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' surance 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 I BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and penalties ofperjury,that the information on his application is true and complete. FIRM NAME: , C>� < II ` C 4 i. LTC.NO.: 3� q16 Licensee: _ Signature LTC.NO.: (If applicable,enter "exempt"in the license number ine.) Bus.Tel.No.:_`�2 � c/ .,�S-6 6 Address: 0� f ku v S" v\ 0+ J, 6 t d UGN Ck V 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)❑owner ❑owner's agent. Owner/Agent PTA T.�EE. $ � Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass F71 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed '� Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comment ? � z - - s Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massa chusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.rnass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FHXD WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Let=ibly Namef(Business/Organization/Individual): J C)t/t Vl Address: City/State/Zip: lou C Sk— t t Phone#: 7 7 g Are you an employer?Check the appropriate box: Type of project(required): IT],17 a employer with employees(full and/or part-time).* 7. 0 New construction I I,d am a sole proprietor or partnership and have no employees working for me in 8. �Remodeling `X any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.C[I am a homeowner doing all work myself.[No workers'comp.insurance required.]t �4.[]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑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. ❑ $ 13.[J�° rep airs • These sub-contractors have employees and have workers'comp.insurance. 6.C[We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 00 152,§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. 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 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: 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 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$250.00 a day against the viola .A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificati I do hereby certi yJ der the pains and penalties of perjury that the information provided above is true and correct Signature: (1 Date: 6 __ 2 .6 S Phone# VI 2 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: E :<GOMMONWE�►LTH OF MASgyUSETT$ . . ® B0,4RD 4l+ CLEGTRICfANS ISSUES THE F" ' I G Lv(rrENSE AS A RED URN,EYMAN :°ELECTR I CI Ahl.. o JOHN M :SCALLt 23 THURSTfN PT GLOUCESTER MA 01930-1650" 32450 � 7 '3l/T6 727342