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Home My WebLink AboutWiring Permit - Correspondence - 201 GREENE STREET 11/4/2014 Date �^ E p10RT/q ,,�.•. •.; ;�. oo TOWN OF ° NORTH ANDOVER i PERMIT FOR WI RING I. B,CHUg� ' 1 This c erhfies � � � e ��that d ® r • I � has permission to perform F �` ada i �4 r,........ wrong inthe building of,•„ z -, ` .�.................. ... ...............at j r Fee ? 9 rth Andover,Mass. Lic.No. ...... Check# � ' INSPECTOR 1 i I j i j Clinmoniveabli ol MamacliaJeffi Official Use Only PennitNo.—dl- 2epaphnent olJipe Sepvice.4 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaeblank) T-- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE, ALL INFORMATION) Date: Zy City or Town of: ,Kjc4Ct-� /4EDe�-2 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) 4- Owner or Tenant 2 to 1 4/2E=-,5L4C-- -;i'7— Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes F-1 No [i] (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd❑ No. of Meters New Service Amps Volts Overhead Q Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: IA4 157)tz-L r ,:,7 5 U Conipletion of the following able inay be waived by the Inspector of fflires. No.of Recessed Luminaires 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- No.of Emergency Lighting grnd. grnd. F� Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Alerting V, No.of Ranges No.of Air Cond. Tons Devices Heat Pump IKW No.of lfCotined No.of Waste Disposers Totals: I ****I**........... Detectionlerting Devices No.of Dishwashers Space/Area Heating KW Local El u 'PPl El Other Connection No.of Drers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivale t Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: z J'e-v---"zx< .c tz7,-, "04A"----L- Attach additional detail if desired, or as required by the Inspector of I'Vires. 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. 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 [Z] BOND El OTHER Fj (Specify:) I certify ,under the pains and penalties ofperjuiy, that the information on this application is t1we and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature LIC.NO.: 14963 (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.:978-682-6262_ Address: 87 BELMONT ST. NORTH ANDOVER, MA 01845 Alt.Tel. No.: 978-375-5734 *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 F-1 owner F1 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts f Department o De art Industrial Accidents -: P Office of Investigations 600 Washington Street Boston, MA 02111 rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC Address: 8713ELMONT ST City/State/Zip: I NORTH ANC)OVER,MA 01845 .. Phone #: 978-682-6262 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 8 4. El 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. # 7 Remodeling ship and have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers' comp. insurance. 9. Q Building addition [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.El I am a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.[0 Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 1.3. Other 'Any 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 a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I ani an ettiployer that is providing worlrers'compensation insurance for my employees. Below is the policy and job site lilfOrmatlOil• Insurance Company Name: FEDERATED INSURANCE Policy#or Self-ins.Lic.#: 9353694 Expiration Date:I MARCH 1,2015 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 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 hereby certify under t e p in a nallies oflierjury that the information provided above is t ue and correct Signature: Date: Phone#: 978-682-6262&978-3 5-5734 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#: zi � 00MM01�1NF,.�IITM<bF,l'VI,��,��HC1'SET'�: B0Ak2pk � >rL1=�C7R1C1kNS � ISSUES THE, FOLLOWIFIG L41EN5E AS A R tr JOURNEYMAN .£L.ECTR-C-1A14„ EFJ15 B BQMBAR� 60 CORM». T iW LL MA 01830 210.- iJ