The URL can be used to link to this page

Home My WebLink About- Permits #12632-1 - 4 HIGH STREET 8/31/2015 Date... z 4.14ORrH 0 o3a TOWN OF NORTH ANDOVER Poo PERMIT FOR WIRING i -w 40.............. '. 44T,Qo CHU This certifies that ....... ,/.............:7::7�.f...... has permission to .......... wiringin the building of........................................................................................................ at .. ............... ....... Wh Andover,Mass. ... Fee e. .......Lic No. ........................ ( .....i ................................ ELECTRICAL INSPECTOR Check ;'w 54 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance witb the Massachusetts Electrical Code(ME C) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVE'R To the Inspector of 1res: .1 r By this application the-undersigned gives notice of his or her intention to perfo the electrical work described below. 7 Location(Street&Number), Owner or Tenant V Telephone NO. Owner's Address Is this permit in conjunction with a building permit? Yes No F] (Check Appropriate]Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead El Undgrd 0 No. of Meters New Service Amps Volts OverheadF] UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingtable may be waived by the Inspector of Wires. f. No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. o Total Transformers KVA No.of Luminalre Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei In- El 1VO-50-YE,mergency Lighting grnd. grnd. Batter v Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. 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 Alerting Devices Tons No. of Waste Dis posers Heat Pump ..........I.KW........... No.of Self-Contained Totals: Detection/Alerting Devices Connection No.of Dishwashers Space/Area Heating KW Local❑F] Municipal n Other Conn uroity tems-* No.of Dryers Heating Appliances KW SecN .of D Sysevices or Equivalent_ No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total:UW Telecommunications Wiring: 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 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 [I BOND [I OTHER F1 (,1;'pecify:) leei-itry, iin(lei-iliepaiiis�ndpetialtifso!fpel pu thatth y,ihqt the i �hatlon on this application is true and complete. 11 ror" FIRM NAME: LIC.NO. ignature LIC.NO.:(If applicable,ent r "exempt"in theIlicense,V11, vline. Bus.Tel.No.: A 7/1 1 //1 A 60 , 0'�� Alt.Tel.No.: Address: L�V � V — *Per M.GI-c.147, s.57-61,security work requires Department of Public"Safoty"S"Line'fflsell Lie.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)F1 owner [I owner's agent. Owner/Agent Signature Telephone No. PPRMIT FEE.- $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the P permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.01 c. 166, § 32,an ; electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 2 ` Failed Re-Inspection Required($.) ❑ Inspectors Common s' �vd✓ Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimaC.COm The Commonwealth of Massachusetts Department of IndustriqlAccWn' ts Office of Investigations 600 Washington Street Boston,MA 02111 Ut www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly v Name, (Business/Organization/fndividual): P'3, Address: �7#: City/State/Zip: Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. F1 I am a general contractor and 1 6. F1 Now construction employees(full and/or part-timo).* have hired the sub-contractors 7. F1 Remodeling 2.E] I am a sole proprietor or partner- listed on the attached shoot.I These sub-contractors have 8. ship and'have no employees Demolition I working for me in any capacity. workers' comp.insurance. 9. Building addition [No workers'comp.insurance 5. We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.n Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.F]Roof repairs insurance required.]T employees. [No workers' 13FJ Other comp.insurance required.] 'Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. T-Horneowners who submit this affidavit indicating they 97re doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 1sproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site information. Insurance Company Name:, Policy 4 or Self ins.Lic. Expiration Date: 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 requiredundor Section 25A of MGL c. 152 can load 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 tip to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwardoilto the Office of Investigations of the DIA for insurance coverage verification. 1do hereby cerilo undgrth0ains and Venalties ofperftay th at the information provided above is irtie and correct Signature: Date: 0 Phone 4: 0 Official use only. Do not write in this area,to be completed by city or foiPH 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 4: