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Home My WebLink AboutWiring Permit - 38 Units - Correspondence - 8/7/2014 Date..... .. � ..1. ............. i 04 NORrH�ti �� : •c .:• °o TOWN OF NORTH A[lIDOVER a PERMIT FOR WIRING ,88ACHU`y�� ?fvA �PYC.Y f 6-s ... .. This certifies that ........................•• �,y r has permission to performs3 �� } "' 1 R �9 a e a .. .................... wiring in the building of...... .••.•. "•"" € North Andover,Mass. at ... .... AL Fee...;11002.,.:........... ic.No.. .............. ppp "" ELE CAL SPECTOR 4 Gheck# (flmmonwea&of Ma46ac4wetb Official Use Only Permit No. 12---)'- 9_�� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] Leave blank 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 TYPE ALL INFORMATION) Date: City or Town of- R+)\ A A)Jdv,CP To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ,')- /../A)z 0 Owner or Tenant 0�V\ C9 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes FX No El (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Yolts Overhead [—] Undgrd F No.of Meters New Service Amps Volts Overhead F Undgrd F No.of Meters Number of Feeders and Ampacity I Locat* n and Nature of Proposed Ele trical Work: �,V\ 0 e J'Al-:2 C)f:_ Completion of the following table may be waived by the Inspector of Wires. No.of No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total formers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above Ei In .of Emergency Lighting - F-1 y No.of Luminaires Swimming Pool grnd arnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS lNo.of Zones of No.of Switches No.of Gas Burners No. InDetectiTn and itiating Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons Heat Pump Number I Tons..........JKW No.of Self-Contained Na.of Waste Disposers 7u ..........1 11, 1.1111-.......... Totals: - u ................. Detection/Alerting Devices Municipal El Other No.of Dishwashers Space/Area Heating KW Local❑F� CSvstems:*onnection No.of Dryers Heating Appliances KW Securi No.ty of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: A- 'T Inspections to be requested in accordance with NffiC 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 F-1 OTHER n (Specify:) I certify,under the pains and penalties ofperjuty,that the information on this application is true and complete. FIRM NAME: DiNucci Electrical Corp LIC.NO.: 14954A Licensee: Darin DiNucci I Signature LIC.NO.: 34973E (If applicable,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)El owner F1 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts Print Form �1 Department of Industrial Accidents Office of Investigations (_ y I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information \ Please Print Legibly Name (Business/Organization/Individual): V cc:, Ca) D-":,C, Address: is 3 � � vf City/State/Zip: O U. . YnA aa1155 Phone#: Are you an employer? Check the appropriate box: Type of project(required): -T`0 I am a employer with 9 4. ❑ I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 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 the in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 101-1 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.ro Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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 isproviding workers'compensation:insurance for my employees. Below is thepolicy andjob site information. \ Insurance Company Name: o.»0 v i1ir U Policy#or Self-ins. Lic.M W a X) - $ L �� Expiration Date: t) t 1S Job Site Address: 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. I do hereby certify under the pains and penalties ofperjury that the in ormad n provided above is true and correct Si ature: C.6 Date: Phone# 7 I 3 -L<() Official use only. Do not write in this area, to be completed by city or tows: 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 M C, .00MMONWALTH OF M�ASSHUS�T w - ih SUES THE F01_LOWING # ::E' R ,GI —1 -ID MASTER ELECT�i C� iz��` RR 11 .P D MUCC I f J` y 637" so >flt �kl(E °ti } �;� , i�t=��o�n �A oz155 1375 OMMONWEALTH'OF 14d I�ECTtCIANS . ISUES 'THE F�OLLAWING t�10E �� EG .JOURNEYMAN ELCE�I_ k s r N C^ 3497 .. .. 071/ G i