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Home My WebLink AboutWiring permit - Correspondence - 58 GREEN HILL AVENUE 12/9/2013 Date.. �•� 4 � :............... pSORTH �.��'° '• 'ti TOWN OF NORTH ANDOVER p PERMIT FOR WIRING BACHug+ This certifies that ....�� ....... ... • .. p has permission to perform . d ..:. . ... E wiring in the building of.....�.. �< ........ .......... ` ................... ................................ ��........ r........ ..;" at ..... ...... ... North Andover,Mass. Lie.No Fee.. . .- , .� ELCAL INSPECTOR v 'Check# 6 Commonwealth of Massachusetts Official Use Only k 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 Code(M1---.0 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ),,52 b City or Town of: NORTH AND OVER To the Inspector o Wires: By this application the undersigned gives,notice of hi )r her inten ion to perform the electrical work described below. Location(Street& Number) (77 Owner or Tenant yj <o P < Telephone No! Owner's Address )1z Is this permit in conjunction with a building permit? Yes ❑F1 No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead [:] Undgrd[] No. of Meters New Service Amps Volts Overhead El Uridgrd F-1 No. of Meters Number of Feeders and Ampacity .41 Location and Nature of Proposed Electrical W rk: Completion of thefilloivingtable may be ivaived by the Inspector of TVires. No. of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above Ei In- No of Emergency Lighting rnd. No.of Luminaires Swimming Pool grnd. g Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo. 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 No.of Waste Disposers Heat Pump Number Tons J.K.W.......... No.of Self-Contained Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal ❑ Other Connection No.of Dryers Heating Appliances K Security Systems:*KW Security of Devices or Equivalent No. of Water No.of No.of KW Data Wiring: Heaters Z> Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent > OTHER: �2 Attach additional detail it desired, or as required by the Inspector of Wires. 131�- Estimated Value,of Elect-ical Work: (When required by municipal policy.) 4 Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE,C V 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [aBOND F� OTHER El (Specify:) I certify,under t7hef, ins andpenalties ofpetjmy that tile information on this application is true and complete. FIRM N, LIC.NO.: Licensee- WIC.NO.: (If applicable,yqter lle.A,enipt 11 in Ily 11 ens�'humbfr line,,),, Bus.Tel. 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)M owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 2- o L- 7 u y� The Connmonwealth oj'Massachusetts Depcu-tnient of'Indtrstilal,4ccidents i ❑' r� Office oj'[n vestigaliorrs c 1 Con�t-ess Stt•eet, Suite 100 b Boston, NIA 02114-2017 .� '=1� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers Applicant information . Please Print Legibly Name (Business/CJrganization/I lid ividual): Chamberlin Enterprises LLC dba Chamberlin Electric Address: 315 Derry Road Suite 9 City/State/Zip: Hudson, NH 03051 Phone fl: 603-595-9473 Are you an employer? Check the appropriate box: Type of project (required): I. I am a employer with 12 4. ❑ I am a general contractor and I employees (full turd/or part-time). have hired the sub-contractors 6. ❑] New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees these sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have wmkets' 9. ❑ Building addition [No workers' comp. insurance comp. insurance." rcgtti red.1 5. ❑ We are a corporation and its I0.0 Electrical repairs or additions 3 ❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. (No workers' comp. right of exemption per NIGl' insurance required.] t c. 152, §1(4), and we have no 12.❑ Roof repairs employees. lNo workcrs' 13.❑ Other ccnnp. insurance required.l "Any al'iplicvit that checks box tf I must also till oiit the section below showing their workers'compensation policy irlibrmation. t Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4'ontiactors that check this box must attached an additional slice(showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-Coll tractors have employees,they most provide their wort<cis'camp,policy number. I«m all employer that is providing workers'compensation insurance Jor nit,employees. Below is the policy and job site information. Insurance Company Name:Technology Insurance Policy #or Self-ins. Lic. #:TWC3301230 Expiration Date: 1/1/2014 .Job S Address: t Site _� � City/State/"Lip s i a ,Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (late). Failure to secure coverage as required under Section 25A ol'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 STOP WORK ORDER and a fine Of ill) 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 hereb ertrfy under the par arttt`penalires of perjui},that the infiMnation provided above is true and correct. Si tnatutc Phone-q: 603-595-947 ---------.......___-- Official use only. Do not►vrite in this area, to be completed by cif►'or town of frcial. City or Town: Permit/License # Issuing Authority(circle one): I. Board of Ilealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:_— �� Phone#: STATE OF NEW HAMPSHIRE BUREAU OF ELECTRICAL,SAFETY&LICENSING NAME:RICHARD Q CHAMBERLIN JR 1. 8220 M ' 2. .� 3. y n. EXPIRES: 11/30/2015 ' OMMONWEALTH1 OF MASSACHUSETTS _ BOARD OF ELEGTRI jANS ISSUES THE FOLLOWING LIE_NSE AS A" ; .. REG-If SERED MASTER ELECTRICIAN RI;CHARD Q CHAMBERLIN 27 ALP I IVY AVElw tV HuosoN Nei o3o5i 4366° _ 774MR 07/31l16 ... _ 47z68 _COMMONWEALTH OF MASSACHUSETTS BOARD OF 1LIECTIR I Cl ANS ISSUES THE` FOLLOWING AS A REG JOURNEYMAN ELECTR I C-I AN ;� RIGIiARD Q CHAMI3ERLI`N JR 27 ALP fNE AVE w �J I t�oSON NH ho3o51-1 366 16 4 �6 Milto