The URL can be used to link to this page

Home My WebLink About- Permits #12708-01 - 1 HIGH STREET 9/23/2015 Commonwealth of Massachusetts Oi iZl Se°�Y Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. iml (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 C 12,00 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: 1 , _ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice_ r of his or her intention to pe form/he electrical wotk described below. 01 Location(Street&Number) ' JIF / t/ �� . C Owner or Tenant ' !i Telephone No. Owner's Address _ Is this permit in conjunction with a buildin 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 No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency Lighting rnd. rnd. Battery Units _ No.of Receptacle Outlets j 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 Disposers HeatPump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local ElConnection ❑ Other No.of Dryers Heating Appliances Key Security Systems:* y No.of Devices or Equivalent No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent ecommunications No.Hydromassage Bathtubs No.of Motors Total HP Tel No.of Devices or Equivalent OTHER: Attach additional detail if destred,or as required by the Inspector of Wtres. 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains n enalti s of er't ry,that the ' rmation on this application is true and complete FIRM NAME: . ' V ,r2 LIC.NO.: �t� Licensee: Signature_ LIC.NO.: I a licable,enter "e em t" ' the license n ine. / 1 Bus.Tel.No.:&WA_ Address: Alt.Tel.No.: 'Per M.G.L c. 147,s.57-61,security wor c requires Department of Public Safety"S"License: 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)❑owner ❑owner's agent. Owner/Agent PERMIT EE: $F Signature Telephone No. I�� Date ..S :� ............................................ f aONTty ti 03� °oL TOWN OF NORTH ANDOVER h mA PERMIT FOR WIRING ,88'®CHUS�� This y9 _ 5 certifies that � � �� has permission to perform V�": ,� T wiring in the building of V ........................... at ......... �.. .° ........ r .s a North Andover Mass. Fee....... .....Lic.No. ........ ........................ ELECTRICAL INSPECTOR.'.................... � Check.# ��c-a The Commonwealth of Massachusetts F Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA 02114 2017 www.mass.gov/dia e^M Sy'�o ovkers'Compensation Insurance Affidavit:Builders/Contractors/E+lectricians/Plumbers. y TOBE FILED WITH THEPERMITTZN'GAi7TTIORI�Y_ Please Print Legibly A ''licant Information n Name(Business[Orgaiiization&dividual): Address: � City/State/Zip: / Phone : Type of project(.•ecluired): Are you an employer?C.eclk the appropriate box: em to ees(full and/or part tune). 7, p New'donstrActlon 1. I am a employer with P y 2: I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required]t 10 0 Building addition 4•❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will l l ❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole bin airs o7 additions proprietors with no employees. T �� g repairs 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 110 R66f re[airs These sub-contractors have employees and have workers'comp.insuranceJ 14. Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no empldyees.[No workers'comp,insurance required.] xAny applicant that checks ho9c#1 must also fill.out the section below showing their workers'compensation policy information. i homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit anew.affidavit indicating such. I 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. • - X am an employer that is providingrvorkers'compensation insurance for°my employees. Below is file policy and jots site information. / - Insurance Company Name: Expiration Date: policy#or Self ins.Lic.#: City/State/Zip: fob Site Address: ` Attach a copy of the workers' compensation policy declaration page(shotiving the policy number and expiration date). olation punishable by a fifib Up to$1,500-00 Failure to secure coverage as required under xM enalties in the form of ais a aS STOP nal rW'ORK ORDER and a fine of up to $250.00 a and/or one-year'imprisonment,as p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cent under the ns an pe alties ofperjury that the information provided above is true correct. _ Date; Si afore: Phone#: thus area,to he completed by city or town offrciaL official use only. Do not write in Permit/License# City or Town- Issuing Authority(circle one): X.Board of health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person: a ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the 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.G.L 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 ifhe 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: Tlrench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signat Date: ROUGH INS CTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com w .. JMMONWEAL®H OF'E1AAS HllSETTS "BonOF CI AN SSUES TWE FOLLOWING ,LI'.CENSE ELECTRICIAN AS A Rl G JOURNEYMAN : a YOUNG & SON ELEClR"i'G C0 w ` M.LROSLAII MLARY , EU 2 BLOSSOM,:5T 'A 01801 5106 39012 32426 `E �'�MMONWI�i�LTH'OF MASSN►CHUSETTS . ® g0ARA OF IGIANS EL .. t:SSUS THE FOLLOWING LECTR ;C?!AN A .. ,. REG#STEREO MASTER: ��- i SON >ELEC` RC�....CO & OUiIC Mfp,OSLA11 S MLAS ;W o 2, BLOSSOM>.ST` Mp 01801 5r06 .. w0S1RN 0T/3 t l 390 3 13847. A -