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Home My WebLink AboutWiring Permit - Correspondence - 21 HAMILTON ROAD 9/11/2014 Date.................. ................... i A0Rry o�°;'"`;;' �ao� TOWN OF NORTH ANDOVER * _ - PERMIT FOR WIRING CHU5E This certifies that�j .... .` f"p as r fl 6.................................................................. � ..... � I�� f 'a t has permission to perform ... `......::.� i....:..:' ......: ..::..I. € wrong in the building of............................................. ......... at .....; ..°...:. .. �.7. ¢................................................................ orth Andover,Mass. Fee. ........Lic.No t �x;� � �� ,y .... ... ...... ......... _ ELECTRICAL INSPECT/�i£ �,A Check# � �� Commonwealth of Massachusetts Offal Use Only (� l Permit No. ®epal�ment of Fire Services k; Occupancy and Fee Checked LL BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL liEllORK All wort:to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 9 `l / City or Town of: N, A,d, "Yr 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 1-1&�z l-A i Rei Al. A-1W"&e 111ZA Owner or Tenant s V// ) Telephone No. Owner's Address ,2/ /blk It 1•f� Al- /g��d!/em s'" 111C Is this permit in conjunction with a building permit? Yes �'No ❑ (Check Appropriate Box) Purpose of Building /�'S/C,� 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 Location and Nature of Proposed Electrical Work: & ke llf'h re zV-4�P Completion of the followin table may be waived by the Inspector of Wires. of No. of Recessed Fixtures No. of Ceil.-Susp.(Paddle)F Transans Total Trsformers KVA No.of Lighting Outlets No. of Hot Tubs Generators KVA - o, omergencytg ing No. of Lighting Fixtures Swimming Pool rud.Above El In rnd. ❑ Battery Units No. of Receptacle Outlets /0 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. Tonal No. of Alerting Devices No. of Waste Disposers Heat Pump I.Number Tons KW No. of Self-Contained Totals: I I lDetection/AlertingDevices No. of Dishwashers S ace/Area Heating KW Local ❑ Municipal ❑ Other P g Connection No. of Dryers Heating Appliances KW Security Systems: ry No.of Devices or Equivalent No. of Water KW No. of No. of Data Wiring Heaters I Signs Ballasts I No.of Devices or Equivalent No.H dromassa e 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. 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:) (Expiration Date) Estimated Value of Electrical Work: '-a0 0 (When required by municipal policy.) Work to Start: 2 inspections to be requested in accordance with N4EC Rule 10,and upon completion. I certify, under thepains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: ll / LIC.NO.: Licensee: yt,o f SG> All Signature LIC.NO. (Ifapplicable, enter "exempt"in th license number line.) a Bus.Tel.No.; 7'7/ Address: 1G/ !r 0 Alt. Tel.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 El owner's Page Owner/Agent PER-AHT FEE: $ `� Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 sv ,4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1�f q-177es Address: ql gl I/er-f l�� e City/State/Zip: /V-ea'fi,Y-/ IIZ/ 0d-/YSf Phone#: Are you an employer? Check the appropriate box: 'Type of project(required): 1.❑ I 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 2. I am a sole proprietor or partner- listed on the attached sheet. $ ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity. workers' comp.insurance. 9. ❑ 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 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑ Other V comp. insurance required.] kAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, kContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site %nformation. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: 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 Df 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. t do he certify under the pa sand enalties of perjury that the information provided above is true and correct. Si ature: Date: 'hone# 617" 71 ��d 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. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: . ..... . ...... ....................... . �nA�1 1H1NEAL1`H �F MA SACHUSETTS w a BOARp o EI��ECTR'f C I ANS �� ISSUES THE FOLLOwl NG"L I CENSE AS: A RAG JOURNEY MANELECTRICIAN JAMES' J SALVATI 419 RIVERSIDE AVENUE MEDFORD MA 02155 4946 i 1 39366 E 0"if/31/16 10954o c w~ NMI �� 1