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Home My WebLink AboutWiring Permit - 12856-1 - Permits - 4 HIGH STREET 11/12/2015 4-s Date.... V40RTIJA TOWN OF NORTH ANDOVER o? PERMIT FOR V1/MING j ACNUg� This certifies that .. e has permission to perform ...•• ��¢ II f. ` .. ..................... �. r in the building of... wiring Mass. _ de Qys North Andover, • ...................................f Lic.No. •....... Fee.........:.................... ..................... ELECTRICAL INSPECTOR Check# t Commonwealth of Massachusetts Official Use _ ly Department of Fire Services Permit No, Occupancy and Fee Checked r` 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 IN INK OR TYPE ALL INFORMATION) Date: ab��r� C'6 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to T th electrical work described below. Location(Street&Number) -�)() Owner or Tenant Telephone No. S�6 =— 7v Owner's Address Is this permit in conjunction with a building permit? Yes 5r No ❑ (Check Appropriate Box) Purpose of Building 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: A:lk , Completion o the followingtable ma be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil: Trans Susp.(Paddle)Fans ot Trformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ElIn- ❑ o.o mergency ig ng nd. nd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of Detection and No.of Switches No.of Gas Burners o. Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number ..........................ons KW No,of Self-Contained p Totals: Tons ...................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Cyonnection No.of Dryers Heating Appliances KW ecurit No.of Devi es or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Ar No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin No.of Devices or Eq uivalent OTHER: Attach additional detail ifdesired,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. 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 cove;age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains a_nd!pen of perjury,that the information on this application is true and complete. FIRM NAME: ° LIC.NO.: ',. Licensee: - Signature C G,4& �" LIC.NO.: J "� ,7t` (If applicabl, nter "exempt" n e'.liI gense number MIL nn Bus.Tel.No.: �x_ /,s ue Address: ,31? klj(b ')l ruIL 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)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ 5— Signature Telephone No. The Commonwealth of Massachusetts Department oflndustrialAceldents 1 Congress Street, Suite 100 f.d Boston,MA 02114-2017 }V0y6W4 wwwanass.govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Elpetricians/Plumbers. TO BE, FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib� Name (Business/Organization/Individual): Address: City/State/Zip: .:� �,.. . L Phone#: .M._ Are you an employer?Check the appropriate box; Type of project(x•equired): 1.❑I am a employer with employees(full and/or part-time).* 7. C]New construction 2."° a sole proprietor or partnership and have no employees working for me in 8. [Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3,Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. I2.F]Plumbing repairs or additions am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs T 5 I hese srib-contractors have employees and have workers'comp.insuranco.t „ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL G. 14.[]Other .w..g '.. IS2,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Ilomeowners who submit kris affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContraetors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not,those entities have employees. If the sub-cm&aciors have employees,1hey must provide their workers'comp.policy number.' I am an employer that is pi^dvidhig ivorizers compensation insurance for nay employees.' Beloiv is the policy and job site information. Insurance Company Name: Policy##or Self-ins,Lic.#: Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to seeure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Date. � is true and correct. r a es o er z[r that the in formation rovided a 1`p j y f p hereby certify Z�zns and, / ' S�nature cer•tz cn�er ae. . t ..°° Phone Official use only. Do not ivrite in this area,to be completed by city or tolvu official,, City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: z COMMONWEALTH OF MASSACHUSETTS Boa�n Q I.LEGTRI C''I AN5 I SSUES THE `FOLLOWING lA':C°ENSE AS, A.-.".REGISTERED SYSTEM TECHNICIANW JOSEPH F LAGANA JR - W 38 ALLSTON STREET: a LAWRENCE ! A 01841 2303 { 17r77 . D.. 0 /31/1 ®MMONlNEALTH OF MASSACHUSETTS a l SOAR OF ISSUES THEEFOLN LOWING IIGENSE AS A REG 1 STERED SYSTEM CONTRACTOR" JOSE;PH F LAGANA"JR An -38 ALLS.TON"STREET; W LAWRENCE M'A o 1841-2303c.;.;; 77 C 07/3l/16 32712