HomeMy WebLinkAboutWiring Permit - Correspondence - 16 GREAT OAK STREET 1/8/2016 i
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Date...........
NoprN
of,
03?• � `� •• OIL T
OWN OF
NORTH ANDOVER
PERMIT FOR WI
� •a�r�T:.;:•' RING
SBACHUS��
1
This certifies that
has permission to erfo
P rm
wiring in the ,
building - --� •••
at
¢D•G .........................
d ..
..... .....
..........,North=A
Fee... ..�...................Lic.No ndov er,Mass.
Check# EcEcriucn 1t:
INSPECTOR ........
1 '
❑ 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 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass V Failed 0 Re-Inspection Required($.)❑
Inspectors Comments: 1
c �
Inspectors Signature: Atl Date: f
ROUGH INSP TION:
Pass M Z Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
r
❑ 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 M Failed Re-Inspection Required($.) ❑
Inspectors Comments:
J
Inspectors Signature: Date:
0
SERVICE INSPECTION:
Pass M Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL VOUGH INSPECTION:
Pass M V Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSP TION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: —Date:
FINAL INSPECTION:
Pass F?1 Failed M Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
..The Commonwealth of Massachusetts
Department o f IndustriaZAccidents
1 Congress Street,Suite 100
d 02174 2017
F Boston,MA
- 9r. www mass.gov/dia
O^M SV'vl
Workers'Compensation insurance Affidavit:Buildexs/Contxactoxs/Electricians/k'lumbers.
TO BE FILETS WITH THE PERMITTING AUTjIORY�Y- Please?2rint Le 'bl
A �llcant Information A J C
Name(Business/Organization/lndividual):�__,_____
Addxess: V _ l ZZO
Gtl��c�,�< G A-01 Phone#: �
City/State/Zip: • . ,. : ....:t�•, ..
Are you an employer?Checic the appropriate box:
Type of project(reciuired):
1,uam a employer with__._,Lemployees(full and/or part time).
7. []Nevv'donstriiction
2.E]I am a sole proprietor or partnership and have no employees vtorking forme in $. Remodel3itg
any capacity.[No workers'comp.insurance required.] 9. ❑Demolition
3.�lam a homeowner doing all work myself[No workers'comp.nisurance required.]t 10 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11 Electrical repairs or additions
J
ensure that all contractors either have workers'compensation insurance or are sole 12 bin repairs Or additions
proprietors with no employees.
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
11 FI Ro6f repairs
These sub-contractors have employees and have workers'comp.insurance.t 14. Othcr
6.QWe are a corporation and its.officers have exercised their right of exemptiou per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
xp ny applicant that checks box#1 davit indicating they are doing all work and then hire outside w showing their w e contractors actors must submitmaau w affidavit indicating such.
Homeowners who submit•this affidavit
TContractors that check this box must attached ha additional sheet showing the name of the sub-contractors and state whether or not
(hose entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
X am an employer that is providing workers'compensation insurance for my employees- .8elow is the policy aradyoti site
information.
Insurance Company Name: '_°' J _e 1_` J 5
Expiration Date:
Policy#or Self-ins.Laic.#: / •
'T v.A-� City/State/Zip: /Lr, .�/y�.�c�U-e✓�
fob Site Address: /Co ��
Attach a copy of the workers,compensation pokey declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL e.152,§25 orm of
violation
STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment,as yell as civil penalties in the f
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
X do Hereby cent�Uertlze
p ' andpenalties of peryrcry that the information provided alcove is true and correct.
Si ature:
Phone#:
Official use only. Do not-write in this area,to be completed by city or torpn official.
Permit/License##
City or Town:
Issuing Authoa'itY(circle one):
3.city/Town Clerk <!•.Electrical Inspector 5.Plumbing Inspector
1.Board of Health 2.Building Department
6.Other
Phone#:
Contact Person:
EG1S1`ERD MASTER ELECTR"1GIA�1 .�.
LAURI)UO ELECTRI"C CQti'AN"Y iNC
F-AN J LAF1R 1 NO.
15 "MYRTLE STREET
W13uRNa o IS
01-5016
2o12t3 :A"' 0 /31la6 52494
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