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Home My WebLink AboutWiring permit - Correspondence - 22 HARKAWAY ROAD 11/13/2014 Date.. '.. ,-I................... �NORTM 4 TOWN OF NORTH ANDOVER PERMIT FOR WIRING $BgCK r This certifies that .. `€ ... ................... r ...... E has permission to perform ..:; ....,..:... ....E... ... wiring in the building of. . r ` r e* s. �2 ......... .......................................North Andover,Mass.. ..... �.........., .... ......... F. .....Lic. No. t..,> `f ........... . .. �.. .., ( p ELECTRICAL INSPECTOR fl Check# tY rr�,� �s.0' Cry d Commonwealth of Massachusetts Official Use Only Permit NO. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C d (MEQ,527 CMR 12.00 "(PLEASE PMTINIATK OR TYPE ALL INFORMATION) Date., �L�Q k,` City or Town of: NORTH ANDOVER 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) Z.2.- Owner or Tenant A�2hk-p,-,o 6- LcA I Telephone No. Owner's Address S�kv-t 6- Is this permit in conjunction with a building permit? Yes D No El (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service_ Amps Volts OverheadF] UndgrdF] No.of Meters New Service — Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 11-00 Campletio�vfthe following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 7-- No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above Ei In- r-, No—.—OTEmergency Lighting grnd. gr-nd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo, of Zones No.of Switches No. of Gas Burners No.of Detection and S� Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No. of Waste Disposers Heat Pump KW No.of Self-Contained Totals: 9M.......... Detection/Alerting Devices Municipal E] 0 No.of Dishwashers Space/Area Heating KW Local❑El Connection ther No.of Dryers Heating Appliances I(W [Sic—urity of Systems:* No. Devices or Equivalent No. of Water 1CW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent Wirin : No.Hydromassage Bathtubs No.of Motors Total HP Te No.of Deviceslecommunications or Eauivaglent OTHER: J0 Attach additional detail if desired, or as required by the Inspector of Ores. Estimated Value qElccVicalWork: 3 ,9oo,, (When required by municipal policy.) Work to Start: L(_ -,'? - 0 inspections to be requested in accordance with IVIEC Rule 10,and upon completion. I Ll- INSURANCE COVE 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 cover geis in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND 0 OTHER F1 (Specify:) I certify, under fil Pains rind penalties ofp eilwy,that the information on this application is true and complete. FIRM NAME: fl LIC.NO.: Licensee: (If applicable, nter "exempt"in the license number line.) Bus.Tel.No.: D *Per M.G.L c. 147,s.57-61,security work requires Department o Public Safety"S"License; Lic.Na. � OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. $y my signat«re belaw,l hereby waive this requirement. I am the(check one)❑owner ❑Owner's agent. Owner/Agent Signature Telephone No. FEE.- $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of XG.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and maybe deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Ins ection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection:Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Com nts: S y � Inspectors Signature: dv Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments:, Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department oflndustriglAccWd is Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/rlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri.citansfPlulmbers Applicant Information Please Print Legibly Name(Business/Organization/Xndividual):—Z-- c—, C' Address: P-o iQ 3S City/State/Zip: (I'll" L,_UU-t_ , AAA — Phone#: al`2 fs 7) ?S--U&6 Are you an employer?Check the appropriate box: - Typo of project(required): 1.Eft am a employer with/__ 4• ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ,/ [ temodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet,t ship and'have no employees 'These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. y, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.) officers have exercised their 3.❑ I am a homeowner,doing all work right of exemption per MGL I LF1 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12,QRoofrepairs insurance .re uired employees.[No workers' required.) comp.insurance required.) 13.❑Other 'An.Tr applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is pro workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name:. 1-k J Policy##or S elf ins.Lic.#: Expiration Date: --�� Job Site Address: Z �Z A �- City/State/Zip: 00L At, �)d J1C:7V_V, 't'L'4, Attach a copy of the workers'compensation 011cy declaration page(showing the policy number and expiration date). t Failure,to secure coverage as requiredunder 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 uli to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invedtigations of the DIA for insurance coverage verification. I do hereby cerfify under the pains and penalties of perjury that the information provided alcove Is true anti correct. Si mature: Date: Phone#: 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Vnnfnv Parcnn! • Phone#: