HomeMy WebLinkAboutWiring permit for 77 units - Correspondence - 8/7/2014 I
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Date.. ...............
u OF P10RTN,�
03�,•' ..: ,. oo� TOWN OF
NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that
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has permission to perform I�
wiling in the buildin
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Fee ` ' 5 f
N h Andover Mass.
... Lic.No ` �t � i e _ .
........ ...........
�-�-� _ ELECTRICAL INSPECTOR ............
Check# _�_ E
lfommonwe-J4 o/M16e1W4UJetb Official Use Only
c� c� Permit No.
2epartment ol._Y'ire seruicee
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank)
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APPLICATION FOR IT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATIO ) Date:
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City or Town of. CJ \ ANcA To the Inspector of Wires,
By this application the undersigned gives notice of his or her intention to perform-t7he electrical work described below.
Location(Street&Number) tAgoe 5 'r Dv\ _ 1
Owner or Tenant �j�fj 6A 1\ P, "7 A `7-Q Telephone No.
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❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Locati n and Nature of Proposed El e trical Work:
r -� -
- Completion of the ollowin table may be waived by the Inspector of Wires.
No.of Total
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- o.o Emergency fg mg
No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No. I Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons J.KW No.of Self-Contained
p Totals: Detection/Alertine Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
ry No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Si ns Ballasts No.of Devices or E uivalent
dromassa a Bathtubs No.of Motors Total HP Telecommunications
No.H Wiring:
y g No.of Devices or E uivalent
OTHER:
6< Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: t?--°�'0 (When required by municipal policy.)
Work to Start: .-A, Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO VE RAGE: 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 0 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: DiNucci Electrical Corp LIC.NO.: 14954A
Licensee: Darin DiNucci Signature --- "" LIC.NO.: 34973E
(Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.- 781-395-4750
Address: 637 Boston Ave, Medford, MA 02155 Alt.Tel.No.: 617-697-8266
*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 by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
' The Cott«tr:vtlwenth of 1Vlassae%rrsetts
�epariment of Industrial Accidents
Office o f Investigations F
k 1 Congress.Street, Suite 1 a0 �
Boston.MA 02114-2017
www.massgov/dial'
.,orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
cafifInformation Please Print Legibly
INK
f'(Business/0rganizaEion/Individual): V LG� � c�r; l r�„
less L 3
State/Zip; Ytil o a 1 Phone#:
iu an employer? Check the appropriate box:
Am a employer with
9 4. ❑ I am a general contractor and I Type of project(required):
mployees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
am a sole proprietor or partner_ listed on the attached sheet. 7. ❑ Remodeling
These sub-contractors have
hip and have no employees 8. F—1 Demolition
corking for in any capacity. employees and have workers'
9. [JBuilding addition
Vo workers' comp. insurance comp. insurance.+
squired.] 5. F1 We are a corporation and its 10.❑ Electrical repairs or additions
am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
iysel£ [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
isurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.1" Other_91AA
comp. insurance required.]
dcant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation.
veers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
)rs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
s. If the sub-contractors have employees,they must provide their workers'comp,policy number.
employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
ktion. \
ce Company Name: 11 Q,n 0 yr S, u
or Self-,ins. Lic. M 1.J a x) Expiration Date: 1� 1 IT
Address: City/State/Zip:
a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forin of a STOP WORK ORDER and a fine
$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
rations of the DIA for insurance coverage verification.
re by certitv under the pains and enalties 2(2erZuU that the in ormation provided above is true and correct
ire: Date:
#: 7 3 1 -3 15- - y 15-o
cial use only. Do not write in this area, to be completed by city or town official.
V or Town: Permit/License#
ling Authority(circle one):
loard of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
Mer
ntact Person: Phone#:
7
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