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HomeMy WebLinkAbout- Permits #12767 - 63 HERRICK ROAD 9/24/2014 Date 111 . ...................... 00RTM 0x TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88gcwus� This certifies that has permission to perform �. °....e °.�...:: ....... `............................... wiring in the building of., .. ., .............................................................. ` � ......... .�:..... ° �. ,North Andover,Mass. at .. H ........... .........Lie. No .....�.`....6.. ..�.�..�� �....... ............. .................................... ELECTRICAL INSPECTOR Check 4t v Official Use Only Commonwealth of Massachusetts 11 �L Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. j/o7j (leaveblaak) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PNNTININK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the-undersigned gives notice of his or hpr intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant b to Telephone No. Owner's Address c V Is this permit in conjunAion With a:b7u'lding permit? Yes E] No F1 (Check Appropriate Box) Purpose of Building e Utility Authorization No. Existing Service /0 Amps jl,2e -;tvdVolts Overhead M,-' Undgrd❑ No.of Meters New Service Amps Volts Overhead El Undgrd F] No.of Meters Number of Feeders and Ampacity M t�-' h 6 0 ( "?6 IWA vte� 6 Location and Nature of roposed Electrical Work: ty j( el,z 'el)j Completion of the fallowing 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 o In- ❑ Tq-07-0-T11"mergency Lighting grnd. grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo. of Zones No.of Switches No.of Gas BY No.of Detection and ners Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices Totals: KW No.of Self-Contained 1.NP.!)R!Nr 1 19R§..................-........... No. of Waste Dis posers Heat Pump Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑r-1 Municipal F] Other L-J Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent ns Wiring: No.Hydromassage Bathtubs No.of Motors Total HP Telecommunicat No.of Devices io orEquivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrigal Work: (When required by municipal policy.) Work to Start: —W 9/j,X Inspections to be requested in accordance with MEC Rule 10,and upon completion, INSURANCE COVE RAG a nless 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 F1 BOND F] OTHER [I (Specify:) I c ertyyj, x i n(lei,4,th a 1,*sand P en all* jq eju iy,th a t th e inforn i a tion on this application is true and complete. FIRM NAME: LIC.NO.:A)s-6 Licensee: Signature r LTC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No. Address: Alt.Tel.No.: JY *Per M.G.L c. 147,s.57-61,security work 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)[I owner [I owner's ag_ent. Owner/Agent Signature Telephone No. PPRMITFEE.- $ rw-) The Commonwealth ofMassachusetts " .bepartment o,fXndustrigl Acelde is Of flee of Xn-Pesttgations 600 Washington Street Roston,MA.02111 www.mass gov/tlia Wo rkeo' Compensation Insurance Affidavit:BuR Era/Contr ctor>sfElectri*clans/P�limbers A,.`ppReant Wormation Please print LeWbly Name(Business/orgaozation&dividual.): Address: City/State/Zip; Phone#: .Are you nn employer?check the appropriate box: Type of project(required): 1, I am a employer with 4. ❑I am,a general contractor and I 6. ❑Now construction employees(fall and/or part-time).* have hired the sub-contractors 2. am a sale proprietor or partner listed on the attached shoat, 7- El Remodeling shYpand'lavena.employees These sub-contractors have 8. El Demolition woA ng for me in.any capacity. workers' comp.insurance. 9. Building addition [No workers' comp.insurance 5. ❑ We are a corporagon and its 10 L]Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.❑Plumbingrepairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no UPRoofrepairs insuxancerequixed.] employees.[No workers' 13 Cl Other comp.insurance required.] Mny applicantthat checks box#I must also fill outthe section below showingtheir workers'compensation policy information. 'Homeowners who submit Ws affidavit indicating they ale doing all work and then hire outside contractors must submit a now affidavit indicating such. tContractors that cheA this box must atfached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X arts are employer that isproviding woYkers'eompetasation insurance formy employees Below is thepolicy anrijoh site information. Insurance Company Name% Policy#or Setf~ins.UG.#: Expiration Date: rob Site Address: City/State/Zip: Attach,a copy of the workers'compensatlonpollcy declaration.page(showing the policy number and expiration date). Failure to secure covexagops required under Section 25A ofMGL o.152 can lead 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the MA for insurance coverage verification. .1'do I'iereby certz flee pains an e ties o,fperjury treat Me information provided a ove zs 4ae and eorrect, Signature: Date: Xl)-� 71 Phone Official use©.ttly. Do not write in this area,to be completed ly city or town offteial: City or Town: Permzt/. eense 0 Issuing.Authority(circle one): 1.Board of Health 2.Building Department I CIWT- own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Pers on: Phone#: r. :COMMONWEALTH OF MASSACHUSETT:S ® . Boa o ELECTRICIA S ISSUES THE FOLLOW(�!G LICENSE AS Pi .:REG JOURNEYMAN>ELECI.R''I C I Ia I GLENN M SILVAy W U 222 BOG BROOK RD Nf:W BOSTON f1H 03070 5011 16 82 6 bohAMONWEALTH OF MA' HUSETTS ":BOaE "-OF El'ECTRI C i xidS ISSUES THE .FOLLOWING LICENSE AS � REGISTERED MASTER ELECTRICIAN ' M S I LVA 222 BOG BROOK RD J NE'W 'BOSTON , :.'NH 03070 50.1.1