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Home My WebLink AboutWiring permit - Correspondence - 70 GREEN HILL AVENUE 10/26/2015 ........... of p►ORTH 4ti o TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING Bg�CHUS� This certifies that ......... ........ ..... .......................................... has permission to perform �� ' I � `� ° ,. wiringin the building of......... o c j�....................................................................... at IQ North Andover,Mass. Lic.No ..� .......INSPECTOR........................ ELECPRiCAL Check 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 perfonned in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE,ALL INFORMATION) Date: City or Town of: NORTH ANDOVLi R 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) 70 &Vce-vO Owner or Tenant Vby` .�ouv_ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building S-,N 5�. k -/ Utility Authorization No. Existing Service 10 Q Amps � 2�,O/ aL/QVolts Overhead 0— Undgrd[I No.of Meters New Service ZCX) Amps -\4X0-/',)-VQVolts Overhead.®----iindgrd [I No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be ivalved by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA Above Ei In- No—.of Emergency Ligut-15-2 No.of Luminaires Swimming Pool grnd. ❑ grnd. El Battery Units No.of Receptacle Outlets No.of Oil Burners FM ALARMS No. of Zones of Detection and No.of Switches No.of Gas Burners No. Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Rea Number Tons..........J.KW No.of Self-Contained No. of Waste Disposers Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local[] Municipal n Other Connection No. of Dryers Heating Appliances KW Securoity S Devices of es or Equivalent No. of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP Na.of Devices or Eauivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: L1000 (When required by municipal policy.) Work to Start: 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 ®'BOND 0 OTHER F! (Specify:) I certify, under thepains and penalties ofpeijuiy,that the information on this application is true and coin fete. p FIRM NAME: ?,Cr, r-CGr -C- LIC.NO.: cr-r6 �- LTC.NO.: Licensee: 'c-v-- Signature (If applicable,enter "exempt"in the license number line) Bus.Tel.No.. pi pi Address: Alt.Tel.No.. *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)[I owner El owner's agent. Owner/Agent I APMIT FEE.- $ Signature Telephone No. The Commonwealth of Massachusetts Department of IndustrialAceldents M _ " I Congress Street,Suilte 100 ' d Boston,MA 02114 2017 �r www.mass.gov/dia OEM SV.V Workers'Compensation insurance Affidavit:Buiedexs/Conti actoxs/EXectricians/Plumbers. TO BE FILED WITH TgM,FF MITTING AUTHOMTY. Please Print Le 'bl A 'f licant Information �c ) � Name(Business/OrganizationJlndividual : � . Add-ress: ��' Grc f Phone# eLkq--� C'.0 City/State/Zip: scw��'S r^^fl Ol c1U(o Are you an emloyer?Cfieclttlie appropriate box: Type of project(required): to eel full and/or part-time.).* 7. E]Navv'donstru'otion �-m--m_Pl-ycrwith_,4-_bMP y 2,�lain a sole proprietor or partnership and have no employees working forme in 8. Remo deeiiig any capacity.[No workers'comp,insurance required.] 9• ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will l l:[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole bill airs or additions proprietors with no employees. �� g rep 5,1--]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13%0 R06f reli airs These sub-contractors have employees and have workers'comp.insurance.t 14•t a Other . 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no employees.[No workers'comp.insurance required.] *Any applicantthat checks box#1_must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached'an additional sheet showing the name of the sub-contractors and state whether or not(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providingwvorlsers'compensation insurance for'my employees. Below is the policy and job site information. �v L Insurance Company Name: Expiration D0e2 aC�t Policy#or Self-ins.Lic.#: Q G pe V `\( N- -' City/State/Zip: Y\ AA�` vJ d1uLtz— Job Site Address: Attach a copy of the vvoxltexs'coxn.pensation policy declaration page(showing the policy number and expiration date). ed underMGL e. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 Failure to secure coverage as requit and/or one-year imprisonment,as well as civil Pf tell statement may be forwarded to thefft e oenalties in the form of a STOP 0f InvOesgations of the DIA for in ura 00 a nce day against the violator.A copy o coverage verification. X do lier•eby certify uncle'tliepains and penalties of perjury that the information provided wave is true and correct. Date: L(7® Si ature: I Phone#: _ g Official use only. Do not write in this area,to be completed by city or tolvn official. Permit/License# City or Town: Issuing Authority(circle one): 1.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Llectrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: �?� EI.E:CTFt I C I ANS ISSUES THE FULLOWI,NG LICENSE 'REG �(}URNEYMAN E!LECTRI C I AN-- � '� I ' RC CHARD C PICARD1 JR r J 14 GREYSTONERD �1 S MA. o1906-21�6 SAUGU . o2g E 07/31/16 0 R joNWEALTTH'OF MASS, n. m p0A D OF EE.CTR'iCIANS ISSUES THEFOLLOWING LICENSERS A REGISTERED MASTER. ELECTR,ICI"AN Y, R f£H,ARD C P i CARD i' JRLu 14 GREYSTONE RD ! 11US MA ojg06 21) � o :J6 39607 ` 2052o.%R � � p 1 � �.