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Home My WebLink AboutWiring permit - Correspondence - 3 HARVEST DRIVE 204 11/12/2014 P Date .. ..�. ° . �...................... O�p►ORT/�,ti ,• �oL TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ACHUg� @t�� 5 This certifies that ... I ..... .. ..� ... ......... F ........ has permission to perform ............................................................................................ wiring in the building of.....t".,. .. :�.. ............................................................................. �n � ate lay.... .. ..... .... ......... ...: �.........,,No rth Andover,Mass. Fee s . .................Lic.No.&& ELECTRICAL INSPECTOR Check# � Commonwealth o f Mamac"ih Official Use Only ✓Jeparfmani o{ }irg�ervices Permit No. j 2A t(i BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 71 Aleave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 42,00 (PLEASEPRINTININKOR, PEALLIN OR YTIWO Date: �., t By this application the undersrgn g ves)notice of lus or h To the Inspect r of Wires: City or her intention to perform the electrical work described below. Location(Street&Number) « Owner or Tenant r Yl h('1+„) rj - ) it Telephone Noi . Owner's Address ".. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead C] 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: " t Completion o the ollowin table EM be waived by the Inmector o Wires. No.of Recessed Luminaires No.o€Coil.-Susp.(Paddle)Fans NO•of YA Transformers No.of Luminaire Outlets No.of Hot Tubs Generators No.of Luminaires Swimming Pool Above ,❑ - ❑ o.o mergency rnd. rnd. Bag Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS Na of Zones Na of Switches. No,of Gas Burners No.of tection and Initiating Devices No,of Ranges No.of Air Cond. Tens No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Containid �� Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El other Connection No,of Dryers Heating Appliances ICI Security Systems:' No.of Water No.of No.of No.of Devices or Equivalent Heaters KWSigns Ballasts Da No.off Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommu cations iris-1 No,of Devices or uivaent OTHER: t•-y--�, ..,,..µ Attach additional detail if desired or as required by the Inspector of t;'ires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 ains and penaNa of peryury,that the information on this application is true and compide. FIRM NAME: LIC.NO.: ' a Licensee: e» ' Signature J , LIC•NO.: (If applicable,e�nte�r "esemVpt"in the license n r s„re.) Bus.Tel.No.• Urq I Address: \ y � l)� Alt,Tel.No.: *Per M,G.L,c.147,s.57-6)r,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 aRent. n Agent Signature g re Telephone No. �E�FEE: a..,.,.. �.`. € [ 1 727, A-Z � -FkUR ML ; � - AMSMAf, us Comm-m MIR - RON Vw RE y - , 1 _ x Z awl 'M 'I r The Commonwealth of Massachusetts Department of Industrial Accidents �. Offzce of Investigations 600 Washington Street ` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �n Please Print Legibly Name (Business/Organization/Individual): 0 t C S 1 Cif. v — Address:\ City/State/Zip: L„A 4 it$ a Phone#: L4 01 7 I 3 U g Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• ❑ I aru a general contractor and I employees(full and%or part-tune). * have hired the sub-contractors 6. ❑ New construction, 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance.*. 9. ❑ Building addition con [No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No.workers' 13.7 Other comp.insurance required.] *Any applicant that checks box#i must also till out the section below showing their workers'compensation policy information. r 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 workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: 1// t 1� 1 `i t s"y-hj) CQ a',V I C�S Policy#or Self-ins. Lie. #:w C. p Expiration Date: I (�j " f� Job Site Address:94`W .4�Vf�ST ,fir a",� 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify,under the pa' andpenalties of perjury that the information provided above is true and correct. Si ature: V�en �``�--� \ Date: Phone#: I , 3 g o t-. 1 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#:-