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Home My WebLink AboutWiring Permit - 13182-1 - Permits #13182-1 - 4 HIGH STREET 3/14/2016 Date O p10ii Tol TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING �, �� ao• A 88gCMU9� J a This certifies that , �` c `, has permission to perform ............ ,... � .....�..>� wiring in the building of.........A .................................................................. m. s, at %�E��il....... .. e` Nortb/Andover,Mass. ........f.....:..: :� �, J P Lie.No. . rfl D ...................... ... ® �....... E LTL INSPECTOR Check# i Commonwealth of Massachusetts Official Use Only F Permit No. Department of Fire Semces Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.i/07j (leaveblank) 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 INFORMA TION) Date: ❑ City or Town oh NORTH ANDOVER 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)- V Owner orTenant 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. Existing Service Amps Volts Overhead ❑ Undgrd F] No.of Meters New Service Amps Volts Overhead❑ UndgrdE] No.of Meters Number of Feeders and Anipacity Location and Nature of Proposed Electrical Work: "7 1 jomp9tion of the fd1lowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA (p No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires swimming Pool Above ❑ In- ❑ N_o,_o mergency Ig ting grad, grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones of Detection and No.of Switches No.of Gas Burners No. Initiating Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons Heat Pump I.NM.Mb.cr J.Tqn�..........J.KW........... No.of Self-Contained No.of Waste Disposers Totals: I Number.. ........ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Munn'ne ctic1P on F]Pl ❑ Other Co C, Security Systems:* No.of Dryers Heating Appliances KW No Of Devices or Equivalent No. of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices orEguivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total No.of Devices or Equivalent OTHER: Attach 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. :,,, INSURANCE COVE RAGE: 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 [I BONDE] OTHER F1 (Specify:) I certify, un der th e p ains an dp,en allies ofp eilwy,th at the e inforn i a tion on th is application is true e anti complete. FIRM NAME: 76 LIC.NO.: (6, Licensee: Signaturel��1.__ LIC.N0.:,1- 1,0 (If applicable, enter "exempt"in the license number line) us.Tel.No.;C;' ?I/ le"- No.. 0 71 ,2 1 >� , � P 7 "7(- ( Address: , /9"M (,,)I s >Alt.Tel. No. *Per M.G.L c, 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.Na. 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)Q owner D owner's agent. Owner/Agent Signature Telephone No. row—IT FEE: $ k' The Commonwealth of Massq chusetts Department oflndustrialAceidents " I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letsibly � a , Name(Business/Organization/Individual): �" ' -X L e , ', Cy": ,.. Address: City/State/Zip: Phone#: fir" Are you an employer?Check the appropriate box: Type of project(required): 1.„ I am a employer with employees(full and/or part-time). 7. Newconstruction2. I am a sole proprietor or partnership and have no employees working £or 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. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§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 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.' I 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,Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compelisatiou policy declaration page(showing the policy number and expiration date). Failure to secure 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. m f J r y f Date:, s tue and correct. y JJ' f p rallies o r rrr that the info rovrd dab iv ..__. Signature. 4, ,1 X do lrer^eb certify rrnt e t re ar an e , _ `" ✓l Phone#: 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): ].Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: