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Home My WebLink AboutWiring Permit - Correspondence - 57 GREEN HILL AVENUE 9/30/2013 a Date. . ...... r►ORTF► �.,�•� "moo TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING �BACHU 4 This certifies that , .. ...... i has permission to perform . .. .. wiring in the building of.. .........� �.. ° .....P............................................................. e : ............................... ..: ...�6 . .......... orth Andover,Mass at N , Lic.No .....EcrR............. E ............ ..... .Fee ......... ELECTRICAL INSPECTOR i Check# `r �g Commonwealth of Massachusetts official Use Only Department ®f Fire Services Permit No. Occupancy and Fee Checked .OM BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL INFORMATION) Date: 9 30 / 3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to per/firm,h0 electrical work described below. Location(Street&Number) (' AZ�� 0� G�r`�� Owner or Tenant J I TW j�� 4- 1 ` el IA 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. /5 7 7,�-/q - Existing Service /0 0 Amps J201ZIVQVolts Overhead [g/' Undgrd❑ No.of Meters New Service —( Amps fO/ Z Y(,!V O1tS Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Loca io and Nature of Proposed EIectrical Work: i^a/'t 'i✓Z Completion of thefollowing table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o,o merge - ig tmg rnd. rnd. Batter Unitsits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones — �- No. of Switches No.of Gas Iiuriners No. of Detection and N Initiating Devices Total No. of Ranges No.of Air Cond. Tons No.of Alerting Devices No. of Waste Dis Disposers Heat Pump Number Tons IOW No.of Self-Contained p Totals: ..•...... Detee t,ion/Alerting Devices No,of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Devices �= y No.of Devices or Equivalent No. of Water RW No.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices or Equivalent dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: No.H y g No.of Devices or Equivalent OTHER: Atiach 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. C� INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such co rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) .X certify, sander the ains a penaltie ofp rjurly,that the in ornaati n on this application is true and complete. FIRM NAME: � 9'!�' LIC.NO.: L I i"f Licensee: �,5 fr'� C1�t Signature LTC.NO.: (If applicable,a ter "ex e t"in the license number line,j /` �, Bus.Tel.No.: Address:, . X ID , ) �l 6 i`'1� a � 7 � Alt.Tel.No.:11 *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 ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth oflilassachusetts Department oflndustriglAccWiits Office of Investigations 600 Washington.Street Boston,NIA 02111 www.mass gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ejr, �` 11 Address: P,9 8 C) I c) 7 City/State/Zip:_ 1(' � l; �Phone#: 7 �l A,reyou an employer?Check the appropriate box: Typo of:project(required): 1.I`°I I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.El 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. workers'comp.insurance. 9, []$uilding 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 L❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.QRoofrepairs insurance ]ired.re q u employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they iiie 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 their workers'comp.policy information. I am an employer that is,providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Pate: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation Policy ileclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up tc.$1,500.00 and/or ono-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of 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. I do lterehy certify under the pains andpenallies ofperjury i th •nformation provided above is true and correct - I Signatur_ e T � Date: T`" 0 / Phone#: — 1 7 / Ilk Official use only. Do not write in this area,to he 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#: