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Home My WebLink About- Permits #12954-1 - 4 HIGH STREET 12/14/2015 Date.....,.. o�N°pTH�tio ^T®W►y OF NORTH ANDOVER PERMIT FOR WIRING O y * gyp',[ ��'• ,eBACHU`s� A p y p� . .. This certifies that .. .......... has permission to perform wiring in the building of .. ye � ......, No e rth Andover,Mass. f ............ ............. Fee........:.. ......... ELECTRICAL INSPECTOR Check# -------- r Commonwealth of Massachusetts official use Only i Permit No. I ` Department ®f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION T I IT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NMC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives not'ce of is or her intention to perf t electrical work desc 'bed below. Location(Street&Number) �!�' Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a bu'Id' permit? Yes 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: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA q No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In ❑ N-0—.0TEmergency Lighting rnd. grnd. Battery 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 g Tons No. of Waste Dis posers Heat Pump Number Tons "' KW No.of Self-Contained p Totals: """'' " " " Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection _ No. of Dryers Heating Appliances KW Security De isteci s 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 HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated'Value of Electrioal.W M _ (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 BOND ❑ OTHER ❑ (Speci ) X certify,ccndec,the pains and Ides ofpeZ' y, hat the inforn on this application is trice and complete. FIRM NAME t 19 LIC.NO.: Licensee:*enter Signature LTC.NO.(If applicab "e m "zn hee hide t ber It Bus.Tel.No. 6 �1 i� ?6e Address: '>/ � 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: $ Z Signature _ Telephone No. The Commonwealth of Massa chusetts Department oflndustrialAccidents tl 1 Congress Street,Suite 100 Boston,MA 02114-2017 wwwanass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/OrganizationQndividual): Address: City/State/Zip: Phone#: �✓ �%(/ l �� Areyou an employer?Cheek the appropriate box: Type of project(required): 1� I am a employer with_employees(full and/or part-time).* 7. Q New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. "Remodeling any capacity.[No workers'comp.insurance required.] �` 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition �4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. • 12.[J Plumbing repairs or additions 5. I am a genera contractor and hirede sub-contractors listedon e attacheds . ❑ l d I h thb tt thheet 13. 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.Q 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. i Homeowners who subrriif 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.'Belojv is the policy anti 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' compensation 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. I do hereby certify under the iris qhdpenaltiesofperjury that the information provided above is true an c'o/rrect. Signature: / Date: /� / V 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: MO �A uSETTS 1SSULEQ? DC�ANS. a ES TH AS A:;REGOLLOWI:NO JOURNEYMAN L I-CENSE' ELECTRICIAN P1 RLAV SON E!ECTR 1 C B coC r' LO MLApY : RN ;W 32426 MA 01801-51p6 l.6 39012 ®N pp ,pAy' �p pp gg pp t BQARD F D EL,EGTIGIANS' 15SLlES Ti1r FOLLOWINt RGISTRED MASTER: ELECTRSCIAN { �' J SON ELECTRIC CO a 11>ROSLAV $ z ML:A'b �. 2 BLOSSOM ST i.W lVO1�URN MA 0 1801 5106 13847 A 0I/3.1/16 39013 )D '