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Home My WebLink AboutWiring Permit - Correspondence - 162 GRAY STREET 9/15/2015 Date...... NORTH 'TOWN OF NORTH ANDOVER or:''`'•,�''°° PERMIT FOR WIRING ,88ACNV9 . ................. that I This certifies a fi, ,e.� .---� �.......... . i erform ..... ermission to p ' hasp ................. �� z5' Of........... ass. wiring the buildin North Andover,` M ..�.� OR I Llc.No. A ®� ELECTRICAL INSPECT Fee....... .......... 4 check# Commonwealth of Massachusetts Official Use Only Permit No. k,;]? Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. i/o7] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code W_Q), 7CM "12.00 (PLEASE TRTNT ININK OR TYREALL INFORMATION) Date: City or Town of: NORTH ANDOVL4 R To the Inspector of Wires: By tins application the undersig gives notice of his or her ante ri perform the electrical work described Location below. ( )Street&Number 3 '7 Owner or Tenant Telephone No.I Owner's Address Is this permit in.conjunction with a building permit? Yes [J No Fel (Check Appropriate Box) ....... Purpose of Building UtilityAuthorization No. Existing Servile Amps Volts Overhead(P] -Undgrd n No.of Meters New Service Amps Volts Overhead n UndgrdEl No.of Meters Number of Feeders and Ampacity L 7--7 4— L d Nature of Proposed Electrical Worli�, atio n "�( I ,7fin Completion of the fallowing table may be waived by the Inspector of Wires. No.o No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total formers ICVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above o In- No.—Of Emergency Lighting ,No.of Luminaires Swimming Pool grnd. ❑ grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones of Detection and No.of Switches No.of Gas Burners No. Initiating Devices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices Heat Pump 'Tons I KW No.of Self-Contained No.of Waste Disposers Totals: I [........................I................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑n Munle'P tP' F1 other Connection No.of Dryers Heating Appliances KW Security Systeevicms:T No.of Des 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 Wiring: OTHER: I I No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated ValuepElc trical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC Rule 10,and upon completion. INSURANCE * 0 RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee proved s 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 1 BOND [I OTHER F1 (Specify:) I I certify, under 11 alnsandp�nalt' qfpeijuiy,thatthe inj�ortnration tni,this,#plication is true and complete,, FIRMNAME77,pro -'s �Z/ LIC.NO.: Licensee: Signatur NO.: (If applicable Bus.Tel.No.-.. exert in the lie -,41ne) '0 Alt.Tel.No.: rse ntimbei Address- 4��(t�/') , //7 ( *Per M.G.L c, 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below,I hereby waive this requirement. lam the(check one)[]owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $I" The Commonwealth of Massachusetts Department of XndustrialAceidents M w I Congress Street,S cite 100 F Boston,MA 02114-2017 `; Wt www.mass.gov/dia "VworIcers' CompensationZnsuranceAffxdavit:SuilderS/Contractors/llectricians/Plum ers. TO BE I+'ILED WITH THE PEI2:i&T`I'ING,A.UTifORITY. Please Print Le gib A licant Information r/ f � .�.. �4 Tame(Business/ OrganizatiorLandividual): )° l r Address: 1 � ..- ... �'% '. � ° Phone#: City/State/Zx �--- ... ;. . . , Type of project(TeVired); Are you an employer?Clxec7t the appropriate box: eo ees frill and/or part-time).'` 7. New'd6nstrC Won x, ]I am a employer with —m t p Y 2.`�" I am a sole proprietor or partnership and have no employees Working forme in $, Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]# 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 t 1 Electrical rcp,4iXs or additions ensure that all contractors either have workers'compensation insurance or are sole g repairs or additions proprietors with no employees. 12. Plumbin 5.F]I am a general contractor and lbave hired the sub-contractors listed oathe attached sheet. 13,,Fj R66frc�airs These sub-contractors have employees and have workers'comp.insurance.t 14 ether 6.❑We are a corporation and its,officers have exercised their right o£exemption per MGL c. 1 152,§1(4),and We have rio employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 roust also fill out the section below showing their workers'compensation policy information. i Ilorneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContrac#ors that check this box must attached an additional sheet showing the name o£the sub-contractors and state whether of not those entit;es have employees. I£the sub-contractors havo employees,they must provide their workers'camp.policy number. workers'compensation insurance for my employees. Pelow is the policy and jah site X am an employer that is providing information. Insurance Company Name: Expiration D4.te: Policy##or Self-ins.Lie.#: City/State/Zip: Job Site Address: 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 e.152,§25A is a criminal violation punishable by a Eiib up to$1,500.00 and/or one-year imprisonment,as well as civil Penalties OOest ga ions of the DIA.for itas 50 00 a day against the violator.A copy of this statement may be forwarded to-the aFTriv ance coverage verification. X do hereby certify under thepains andpenalties of per jr ry that the information provided above is true and cor'r'ect. Date: Siggatine' Phone#: official use only. Do not write in this area,to he completed by city or town official. City or Town• Perxnit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town.Clerk 4.Electrical.inspector 5.Plumbing Inspector 6.Other Phone#' Contact Person: .COMMONWEALTH OF M�SSACHUSErTS . BOARD OF ELECTRICIANS ISSUES THE. FOLLOWING `LICENSE S' A I G E1 �0 MA C ER 1LEGaAJ C 8}�OTN�.f2S'° HOME 'S CE-S ILu WILLIAM M MEL"VIN JR W 227 MAI'fa'ST w U NOIT" AND0VER MA o1845-2Ci4