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Home My WebLink About- Permits #13298 - 95 HICKORY HILL ROAD 5/11/2015 !; � 1 ! Date...... .u... , ? 40R7H��oo TOWN OF NORTH ANDOVER o PER FOR WIRING :,r # �ssACHU6� ., ....... .... This certifies that • .......... ..k......... has permission to perform � �s.>:ti ` 9 ... ..... . .. wiring in the building o North Andover,Mass. at 1 ! .t...:. �. .. ty h . F. .. 7 t..... ..................i t,•C , Fee !.,, .. ..... .L1C.NO r,\.N......?. ELECTRICALINSM6C bR k i Check# i I` (flwinonwea&ol Vamac4adelb Official U,se Only Permit No. 2epartment ol-7ire Sertlice,4 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CNM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: rr_1 --CA , •UU , City or Town of: (am &k'16IL& To the Inspector of Wires: By this application the undersign gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) I r V r A Owner or Tenant Telephone No. 01(MLAOwner's Address Is this permit in conjunction with a building permit? Yes F-1 No F (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd 0 No.of Meters New Service Amps Volts Overhead F] Undgrd [:1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �\J I CC ho-ndUz anc ,on r)e A Cwnpletion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total ITransformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above Ei In- N 0.of Emergency Lighting arud. grnd. lBatteKy Units Icy I Total I'VA KVA ng S and Devices Devices No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS S No.of Zones No.of Switches No.of Gas Burners No.of Detection and Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number Tons KW No. of Self-Contained Totals: Detection/Alertinar Devices No.of Dishwashers Space/Area Heating KW Local F1 Municipal n Other Connection No.of Dryers Heating Appliances KW ISecurity Systems:* No. of Water No.of No.of No.of Devices or Eguivalent Heaters I(W Data Wiring: Signs Ballasts No.of Devices or Equivale t No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications W1171112: OTHER: No.of Devices or Equivalent \o Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: $200.00 (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 pern-dt 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 n OTHER [] (Specify:) I certify, under thepains andpenalties ofpeijury,that the information on this application is true and complete. FIRM NAME: DIPIETRO HEATING & COOLING LIC.NO.:Al 8265 Licensee: ERIK PIERMATTEI Signature LIC.NO.:40803 E (1j'applicable, enter "exempt"in the license number line.) Bus.Tel. 978-372-4111 Address: 5 SOUTH SUMMER ST BRADFORD MA 01835 Alt.Tel.No.:978-994-0725 *Per M.G.L. c. 147,s. 57-6 1,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)E] owner El owner's agent. Owner/Agent Signature Telephone No. FERNddT SEE: $ 14) k, 0� The Commonwealth of Massachusetts v Department oflndustrialAccidents I Congress Street,Suite 100 0< Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation insurance Affidavit: Buiidet•s/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leaibly Name (Business/Organization/Individual):DiPietro Heating and Cooling Address:5 South Summer Street City/State/Zip:Bradford MA 01835 Phone#:978-372-4111 Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 30 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.F�1 am a homeowner doing all work myself.[No workers'comp.insurance required.] 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 1 I.❑✓ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p 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.❑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. 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. lain an employer that is providing workers'contpetisatiort insurance for my employees. Below is the policy and job site information. Insurance Company Name:Merchants Insurance Group Policy#or Self-ins.Lic.#:WCA9098545 Expiration Date:07/25/2015 Job Site Address:95 Hickory Hill Road City/State/Zip:N. Andover MA 01845 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 pains at ntiis'trfpexv that the information provided above is trite and correct. Si nature: Date: Phone#:9783724111 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 Cleric 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CONTROL# 0 IMPORTANT If your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. 98 rG5 6oi�o. Hj as3wNYtt 210 W111d H0338 5Z j ❑� 13 i dS 'J 3;1 d 3 1I l 2t 3 ON I lV3H ON I d 10 tl. Hd 3 0 N1�I��It)1a313 U315t/W 03213iS;�� ` S� `3SN30.1 i ONIM071;03` 3HI S3f1SSI `SLL35{IH y+SS W`�O Hl`1J/WNOWWO 4