HomeMy WebLinkAboutWiring Permit - Correspondence - 157 GREENE STREET 6/20/2013 Date (=
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TOWN OF NORTH ANDOVER
* PERMIT FO R WIRING
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This certifies that n` °� � rr t (3
has Permission to perform � QR
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wiring in the building of.....
at
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.........,North Andover,Mass.
Fee ..:.......Lic.No. ELEa �� +
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C MCAL INSPECTOR
Check# �
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lmmonfveaNt o� adbac tieeta
Permit No.
Apartrned ol3ire Service] i
-�� Occupant% and I-cc Checked
BOARD OF FIRE PREVENTION REGULATIONS ; Rey. 1107
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Ail cork to be pertorined in'accordance with the AMassachusetts Electrical Code OJE ').527 MR 12,00
(PLEASE PRIVT LV IrY OR TI"P ' lLI. L\'t It1t.I7CU:�`i Date: �
City or 'I'o��tt of: j0f)u _ To the Ir2spee or o h'ires:
By this application the undersiwned Gives notice of his or her intention p dorm the electrical work described below.
Location (Street & Number) fS,7
Owner or"Tenant ,/7 Zz Ile, Telephone No.
Owner's Address , Sqme
Is this permit in conjunction • h a b cling permit? Yes F No ❑ (Check Appropria Box)
Purpose of Building (Y1 C'tilit� Authorization No. /1� / (�
Existing Service •imps ARC)/�6N'olts Overhead Undgrd❑ No, of�•I etc rs
New Service Arups Volts Overhead ❑ C•ndgrd ❑ No, of Meters
Number of Feeders and Ampacity —
Locati n and Nature of Proposed Electrical \\' , _ _
am lesion of the jolloirine cable urns•be a aived br the hrs pector of Wires.
No. of Recessed Luminaires No. of Ceil.-Susp.(Paddle) Fans No,of Total
_ Transformers KVA
No. of Luminaire Outlets No,of Hot Tubs Generators K\'A
No. of Luminaires Swinuning Pool Above ❑ In- El . o Emergency Lighting
rnd. rnd, Battery Units
No.of Receptacle Outlets No. of Oil Burners IFIRE ALARMS No. of Zones
of
No.of Switches No, of Gas Burners No. In Detection and
Initiating Devices
No. of Ranges No. of Air Cond, Total No,of Alerting Devices t
Tons
No. of\Vaste Disposers Heat Pump Number Tons K\\' No.of Self-Contained
1 Totals: ...... ........... . ...... i Detection/Alerting Devices
i
No. of Dishwashers Space/Area Heating K\\' gLocal❑ \Municipal ❑ Other i
Connection-
No. of Driers Heating Appliances M\' Security Svstems:Y
_ No,of bevices or E uivalent
No, of Water h\V• No.of No, of Data Wiring: �
Heaters Sins Ballasts No.of Devices or Equivalent
No. llydromassaae Bathtubs No. of Motors Total 11P Telecommunications
b No.of Devices or E2iivalent
OTHER:
—� .411ach aiditiom-d derail ff desire(l,or as required br the Inspector q(ff'i es.
Estimated Value of El ctrical \fork: �� r ( \'hen required by municipal police.)
Work. to Stall: Inspections to be requested in accordance with MEC Rule 10.and upon completion.
[NSC R•\NCE CO\'F 2aGE: Unless waned 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 me
undersigned certifies that such coverage is in force. and has exhibited proof of saute to the permit issuing office.
CHECK ONE: iNSURANCE g BOND ❑ O•TI-IER ❑ (Specify:)
1 certrtr,rnuler t/re pains rrnrl pet:ulties of perjtu.t, tlrrrt the inJornxrtinn on this application is true and complete.
FIR\I NA.\IE: /►7Q� � _ 1,1C. NO.: A
Licensee: lrC_�/LJ�1/�(� Signatu LIC:. NO..
/i'applic•uhlr• Truer �X0111/»"ill the lic•emt,rrrwr�,�r linr.� / M- d Bus,Tel, No, �
Address. cam !//2fY'/✓31dIG Q�hIJ /�! r ®1 !l _. .tit. ---
'Per ALGJ_. c. 147. s. �7-G 1.security ��ork requires I�eparunent of Public Sai'etc "S" License: I,ic, No. _
O\\•NEWS INSURANCE \1:U\'F,R: I am aware that the Licensee does not kwe'the liability insurance co\eraue normally
required b\ la\%. B\ IM siznature bcIm\, i hcreb\ \\akc this requirement. I am the(check one) owner ❑owner's a-mnt•
Otitincrl:lcJent C
Signature _ Telephone No, PIsR:tIIT 1''!:E: ti
The C ominoll it'erlr 11c'huse11.5
De1)artmerrt o f Ir,rhrr.;triwl I ccitic my
' �.�+ Uf fice of lrri'e.Stlylltlt)11.1'
600 iI tishitr ton Street
>> Ijoston, .11.-1 02111
. . : u•tt�tt+.rvuss.,ot•/tlin
Workers, Compensation Insurance Affidavit: 13uilders/Contracto►•s/I lectriciuis/I'lumbe►'s
Applicant Information Please Print Leoiblv
Name m.,,sinc,>r rg,ir:/,I•; +:,
Address: AA c
City/State/Lip: Phone ':
Are cots an employer? Check thchppropriate box: Type of project(required):
1. 1 am a em hover\\ith , 4. ❑ 1 am a general contractor and I
1 6. ❑ N\\c construction
enlpkl}'ees(full and or part-time).* have hired the suh-contractors r-,
�.Eli and a sole proprietor or parmer_ listed on the attached sheet. 7. J Remodeling
ship and have no employeesThese sub-contractors have S. U Demolition
working forme in an\ capacity. employees and have workers*
i :. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
5. — `<1'e are a coi poration and its I O.0 Electrical repairs or additions
required.] F �
?.❑ 1 am a homeo\\ner doim all \\o-k officers have exercised their ! I.❑ Plumbing repairs or additions
myself. (No workers, comp. right of exemption per JIG(- I? Roof repairs
Insurance required.] ' c. i 52. >1(4). and we have no
employees. [No workers'
13.0 Other
comp. insurance required.]
":AItv applicant that cheeks boy::I taws:also fill out the seczion b.lntc>110v61,o their workers'compensation ponev infornwtior.
' f tomeomle;s\\ho submit this ai'ida\is ind+caiir.Q the\ are doors all\\ork and then hire ou:side contractors nuts"submit a se\\aliida\;t india+r•na such
contracwr:that check this bo\ruist atl abed at:additional sheet shoe ins the name oi'thc sub-'o021M:tors anu'stag:\\'nether or not dose entities hate
criplo\ees t(;hc sub-contra nor,hate the\ must Prot ide their t\urk.rs'comp.polio nt;rber.
1 am art emplot•er that is prot•i(lin workers'compensation insur«nc•e fur m•emploYees. Below is Late policy«ncl joh site
in for•)rt«time.
Insurance Compam Name: �(Z, ---.----____-- ----- .- ---- -
or Self .. Exliratio; Dae:Police
Job Site;1d(?Tess: n � -� — Cif\ State %ip: t�t,�o
attach , cope of the workers' compensation policN declaration page(Showing ing the polio'number and expiration date).
l'allurc to seethe eo\ejaLe as I-CC'iLEil-Cd Ullder Section 25A of MGL C. 152 caul lead to the ti11pOSltioll Of Ci'iillillal j)CIlaltiCs Of it
Fine up to S 1.500.00 and*or one v ear e"Ir ihlpl'isonment. as Well 'is riv it penalties in the form of a S i'OP WORK ORDER and a fine
of tit' to S2t).OQ 8 (?a\' again>,de \iolator. Be ad\'ised 'hilt a cop\ of t:1ts sta:calCni il•.:'.\ ale i01'\\ardC(i t0 iH �)tt;CC of
t I t t+L
lit\CSll+�3 IOns it: 1C I D1:1 iol' l;lstll'anCC co\C.'t C
— l elo herehr certili•tit lei, its nd Pella ti+ perjury that the infornxttion provided orrect.
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Official rise only. Do not+Trite in This«re«, to he completed hr c•itr or towti oflici«/
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1i < It\ of Eo\\n: I'crntst,I.iccn,c
lssuint", tlthority (circle one):
I. Board of,Ife:tilh ?. liuildim. Deparimunt 3. ( it\%fo\sn (Merl: 4. Electrical inspector Phlnlhin i Inspcetor I'
h. Other I
1 Contact Person: Phone ;
ASTER Lf '} 1
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