HomeMy WebLinkAboutWiring Permit - Correspondence - 1857 GREAT POND ROAD 1/14/2016 Date...... ........ ..............
NOFi TH
��o:,..•�,°.4��c .TOWN OF NORTH ANDOVER
o p PERMIT FOR WIRING
,88ACHU`3�
s tr��&
This certifies that
�°�� �1 .... ......................................
....................
;' e .............................................
has permission to perform ............ ............. ..
wiring in the building of .. .. �.
4
• a
4J" No4. Andover,Mass.
a
� ...... ri
I .. Lic Fee...:.. . ...... o
.....
ELECTRICAL INSPECTOR
Check# `° ---
o�
Cmmonwea&o f VaMac4ubeth Official Use Only
Apartment of Jiro Serviced Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
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 ININK OR TYPE ALL INFORMATION) Date: I —5_z 6
City or Town of: 4 ()r6/ /the- 0 tle j''� To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to erform the electrical work described below.
Location(Street&Number) � � cp J q '"4d Pcecl
Owner or Tenant `� (�t/�� Cc) el' /j 7/ 10* Telephone No.
Owner's Address c� Ct )'yt
Is this permit in conjunction w!,�ll a buil�mg permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building I ze—Yl eo (,/—)• Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: (z� Ire (' e", C� � ����� �e
Conn letion of thefollou,ing table inay be ivaNed by the Inspector of FYires
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 ❑ In- El
o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No. of Ranges No,of Air Cond, Total No.of Aler tine nevire.c
Turin p
No.of Waste Disposers Heat Pump Number Tons 1KW No.of Self-Contained
Totals: Detection/Alerting Devices
No. of Dishwashers S ace/Area Heating KW Local Municipal
p g ❑ ❑ Other
Connectio.. PI
I I.� .. .. IVnnrrritartve4nmc•x' I
No.of ll'Dr yes I nearing Appuances KW
'" No.of Devices or Equivalent
No, of Water KW No. of No.of Data`v�'iriug.
Heaters Su s Ballasts Nn.of 9l r.v res or Fniiiwilent
IA1,. iI...7r........, y-tl.t..L... Ill.. ..f Ai..4,..... T,.4..1 LU
6 v. 1•ru vm—a a> rr.h"' o.v vwlo o"! a
5 !love nc ne•N' rwiyn nn!
OTHER:
Attach additional detail if desired, or as required by the Insaector o�Dr�n es.
Estimated Value of Electrical Work: �� (When required by municipal policy.)
Work t. Start /,.e, inspections to be re;,nested in accordance::ith iAEC Rule l 0,andUn on completion..
ViSURAIVLL L.V VE AGE: Unless waived by 6ne owner,no peraili. Ion the performance of electrical work May Issue(MICSS
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 nermit issuing office.
f'UU1'v ('00 . IAaIUII l\1UAAV L]Cc i I unLAln
V i I rvruvn 1
V1\L. ILUV11 VL LJ V IlLL,1\ `Ullli�ll,'.r G'
I certify,under the pains and penalties of peijuty,that the inforination i this app tcation is trite and coelete.
FIRM NAME: 70k4 eaC LIC.NO.: (J
(Ifopplieable, enter "e,en in the license non t•1'ne.) Bus.Tel. No.:
Address: ��� ('� �/ / j ��) Ci (1f.Tel.No.:
Per M.G.L. ,r'l :7_�:1 ". r."", o".K DeDLI.t, .,t-00f P .iJ. oaf r.,"S,I . � dip ��C
er f•. Gl- ;,�. 1'eq nf'cs u...'l.le.. 1. 1C e , 1Ce 'e: ic. .
ll 1�'\I 1JdE'IJ ili•VI jilU�Al``Ll` i wn all—l t-1 t 1 LldlllJk.V 11V<J!(Vl 11LIVe'the 11(lblllty 121Jtl1 Cll lt.V vVY�1 C1 �11Vr111Cl1IS'�,
required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent
C; TT,tl lIITT T.TT. O,
,...0 Y'.^^-, �3 z.3%-�ii!!e•c. ivi 1 - c.P3 ICC i a T T.T•,r .A
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print. Legibly
a
Name (Business/Organization/Individual): ❑ �eL
Address: -T
❑ty/State/Zip: o/oe/) �, ❑
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with _ 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.4 I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance, 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
14.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGI. I I.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. tNo workers' 13.❑Other
comp. insurance required.] - - —
*Any applicant that checks box HI must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit u 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Li/ � � ��e.#: Expiration Date: f/#'�C1/
Job Site Address:_/ ) ',97 U/00d "(9 �___City/State/Zip: , rd- 0I eC Re-(,as
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 MGI,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 un the pains and pen ties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#:
Of 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#: