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Home My WebLink About- Permits #13221 - 140 HICKORY HILL ROAD 4/10/2015 Date.... .......... ...............f........,. roowrh TOWN OF NORTH ANDOVER o m PERMIT FOR WIRING 9�sACHus�4� f This certifies that fl" ...... "�� .4.. ......, .............. has permission to perform ................ = ..........,.................................... wiring in the building of ; at North Andover,Mass. € f ::....t r ........� 1~ee.. Lic. ....tr, f s...... f........... PLE=CAL I{VSPECTOR Check# r° i Commonwealth of Massachusetts Official Use Only ices Permit No. 3- Department of Fire Sery Occupancy and Fee Chocked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(lv1EC),527 CMR 12.00 (PLEASE PNNTINNK OR TYPE ALL.INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the-undersigned gi tice of his or he intention to perform the electrical work described below. Location(Street&Num�er) lop It Owner or Tenant r'leAq Z: ve- Telephone No. Owner's Address f- Is this permit in conjuZon with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building5io4ll�ic-c 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 41 Location and Nature of Proposed Electrical Work: k-1,A(,0,r:,4_e 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 Luiminaire Outlets No.of Hot Tubs Generators JCVA No.of Luminaires Swimming Pool Above [j In- N-070TEmergency Lighting grnd. grnd. n Satter y Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS iNo. 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 Disposers Heat Pump Numbe ITons IKW No.of Self-Contained Totals: ..............I.. . .......... Detection/Alerting Devices Municipal n other No.of Dishwashers Space/Area Heating KW Local 0 Connection No.of Dryers Heating Appliances KW Securiy S Dysteevices ms:* No.tof or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices oar 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. Vstimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC 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 0 BOND [I OTHER D (Specify:) I cerfify, under thepains andpenalties,ofp`uly,that tlejnformatlon on this application is true and complete. FIRM NAME: . LIC.NO.: /-")7 Licensee: le LTC.NO.:ac,Y$'o 141 //1't e�,OK SignatureC A:411� .76-1 47 (Ifapplicable,enter in the license _j, - exe t niber line.) Bus.Tel.No.- 7p t-)71`07 5�-- 144, Address: 111le A)0 Alt.Tel.No.: *Per M.G.L c. 147,s.57-81,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)D owner F]owner's agent. Owner/Agent Signature Telephone No. PERMIT 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 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 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 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: r; Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments/ Inspectors Signature: Date: FINAL INSPEECTION: Pass M ✓ Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: _ a --- Date: a 5- j DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents d 1 Congress Street,Suite 100 Boston,MA 02114-2017 b�,o•` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information JJ Please Print Ledbly Nalne (Business/Organization/Individual): 4 t ,—✓'efU Address: Ave City/State/Zip: dJ cV - A-�t✓s o,, lq,4 Phone#: 7 V1— S�-yy—l g Are you a employer?Check the appropriate box: Type of project(required): 1.rL II a/m a employer with ` employees(full and/or part-time).* 7. 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.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 FJ Building addition 4.FJ 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.[Al�fflectrical 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑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#I 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 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.Lic.#: Expiration Date: Job Site Address:_/y0 City/State/Zip:/VO- AAnoye-/ 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 nd/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. 1 do hereby eerti and 't e p '�s a penal ' s of per jaly that the information provided above is true and correct. Si nature: Date: d` w 14 Phone#• Sly— 7VJJ 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#: