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Home My WebLink AboutWiring Permit - Correspondence - 8/7/2014 Date ,. EN....-0..................... e 14ORTh TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHUg�� This certifies that ... �' r'" ` ° �' has permission to erforn ..: E �,�`; � ..c u.......... . P P f � wiring in the building of.,..,.; °` `.. . �6 a ... .................... at ... . . ��...... ....:�,, bx.!:... ..1 .'....:, rth Andover,Mass. Lic.NoF c �9 s 9F� .... ....... ........ a:................. .... ..... .. G ELE RIC NSPE. OR Check# � ` (Ifommonwea&of/I"/addac"ef Official Use Only c� Permit No. ` 2— �'� a.Llepartmeru(o��ire�ervicee Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO L I L WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYP ALL INFORWATIQV) Date: City or Town of: QQ�+i N A c� To the Inspector of Wires: By this application the undersigned Ives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 14 6-Koe 5 r D K — Owner or Tenant 04\V11 el) o� "�_C 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 Ele trical Work: 0 e"T (, .nJ s {'+�� - Com letion o the ollowin table maybe ivaivedby the Inspectorof Wires. No.of Recessed Luminaires No.of Ceil:Susp•(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. Elrnd. ❑ Batter 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 Tota No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ....................... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local El Municipal El Other p g Connection No.of Dryers Heating Appliances KW Security Systems:* �'Y 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 No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or E uivalent 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 NEC 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 pains andpenalties ofperjury,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 (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)❑owner ❑owners aaent. Owner/Agent PERMIT FEE: $ Signature Telephone No. file vn iv wealt{z of Massaclutsetts Princ r I?epartrtzent of Industrial Accidents Office of Investigations � 1 Congress Street, Suite 100 - Boston, MA 02114-2017 ` r ww>K.mass govldia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers sCa nt Information Please Print Legibly 1r(Business/Organization/Individual): V C G� � ec�; l fs, „ esS 3 lQ ! F$tate/Zip; a a Phone #: v to an employer? Check the appropriate box: Type of project(required):' am a employer with 9 4. ❑ I am a general contractor and I 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 g• ❑ 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 o 1 self. workers' right of exemption per MGL y � comp. 12.❑ Roof repairs isurance required.] t c. 152, §1(4), and we have no 13.(" Other employees. [No workers' comp. insurance required.] licant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 ition. ce Company Name: \1 an 0%r Sr CIA&u` i or Self:ins. Lic. #: W 21J Expiration Date: 1� 1 l 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 $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. reby cerk under the pains and enalties oLeer'u_q that the in ormation provided above is true and correct ire:I 0,1 " Date: 4: '7 '7 1 - 3 1,, cial use only. Do not write in this area, to be completed by city or town official or Town: Permit/License# Ling Authority(circle one): toard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector )ther atact Person: Phone#: r =S OMMONW LTH`OES i 1 �a y � LI_ 37,#21C1NS�f `rSS;UES THE FOLLOWIf' C s REG�STEI2ED MASTER� L�E , DER GN P D I NUCC Ita ,Y s • i 14954 0l/3 / I, t. IM . .. ,. a' €COMMONWEALTH:rFO,"0.�l�ll ��a� � Tr tnx l i s x