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HomeMy WebLinkAboutWiring Permit 38 units - Correspondence - 8/7/2014 17/.. .. � aoRrM TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1 88ACHU5� t This certifies that ... .... .... :.. ................................................... has permission to perform ..� y : ��...: .. .:.: .,yp ... . .. . � wiring in the building of.,.... ....: y � C .................... e 4a r at ....... ......... ......... ......... ............... orth Andover,Mass. k Fee..... ...., . Lic.No. .............................. ............:L INS ... ... ELE ICAPECTO Check# (fommonwea&of V dbachWeth Official Use Only c� C� Permit No. 7 2epartment ol3ire Jerviee6 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) 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 IN INK OR TYP4 ALL INFORMATIO ) Date: City or Town of: . '�`� %� To the Inspector of Wires, By this application the undersigned gives notice of his or her intention to -erform the electrical)work described below. Location(Street&Number) i.4 P o e Q K Owner or Tenant �jlj C� V .l - Tele one 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 EleItricalWork: � •�,. `� - Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil: p (Paddle)Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. El In- ❑ 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 Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons J.KW No.of Self-Contained p Totals: Detection/Alertinz Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ other p g Connection Dryers Heating Appliances KW Security Systems: No.of D ry No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring y g No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: -A 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 Z BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is trite and complete. FIRM NAME: DiNucci Electrical Corp LIC.NO.: 14954A Licensee: Darin DiNucci Signature_''- "" LIC.NO.: 34973E (Ifopplicable,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: 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 F1 owner's a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. w Thevtrztttonwealtlt of Massachusetts Print is 4 1)epat'ttttent of industrial Accidents Office of Investigations } 1 Congress Street, Suite 100 ' ' Boston,MA 02114-2017 w www.mass.g©vfdia olrkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers J cant Information Please Print Le ibl t(Business/Organization/Individual): VtG� �Q� �; ( „n„ E f� �eSS' 3 :State/Zi ' of M aa1�5 Phone #: 7 �) - S_ P: -? v iu an employer? Check the appropriate box: a 4. I am general contractor and I Type of project(required): am a employer with 9 ❑ 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 hip and have no employees These sub-contractors have 8. ❑ Demolition corking for me in any capacity. employees and have workers' 9. ❑ Building addition Vo workers' comp. insurance comp. insurance.+ squired.] 5. ❑ 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 tysel£ [No workers' comp. right of exemption per MGL 12.❑ Roof repairs isurance required.] t c. 152, §1(4), and we have no t\, employees. [No workers' 13.[,C] r� Other comp. insurance required.] licant that checks box#1 must also fill out the section below showing their workers'compensation policy information. vners 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 pion. ce Company Name: 1I ar,o%r S,r C u #or Self:ins. Lic.#:_ 1k) L 7 7"? Z�9 Expiration Date: o) t Is 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 form of a STOP WORK ORDER and a fine 1$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 certify under the ains and penalties o er'u that the in ormation provided above is true and correct tre: Date: '7 9 1 -31s' - H k-b 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): hoard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector )ther atact Person: Phone#: j Y` Eft 4 o OOMMONWEALTH OFt,M •M M-ir"OV,I On 51 OEM 3QAR ? SSUES ,, RE',-. FOtLOWING�t� GC�� i4 z [EG J S T£R p MAST 4R�L t ,Y DFt�G P D I t�UCC t � t t I 637 U aos�or SE 66 yr 14954 e n �5 COMMONWEALTH°,O,F.M�: v - �� t „.