HomeMy WebLinkAbout- Permits #12763 - 60 HERRICK ROAD 9/23/2014 Date.... ...............
O�OORT/.4
TOWN OF NORTH ANDOVER
I
p PERMIT FOR WIRING
o — p
BACHUSk
This certifies that ... d�
r ........................................................
has permission to perform ....... ...:, ..... .. ................................................................
wiring in the building of........
at ..... f `� '....: �.. .... eJ...u. �t ..... 1'� ..........................North Andover,Mass.
Fee.......1!......... .........Lic. No. ..........:.. . .'.....................................................................
ELECTRICAL INSPECTOR
Check# Q)
�onulwrutlaa[Ut o� a��acicu3olta Official Lise Only
oGJapartnwld aI firu�aruicai Permittao, ���p
BOARD OF FIRE PREVENTION REGULAT1gNS Occupancy and Fee Checked
[Rev_1/()7] pcaveblank)
APPLICATION FOR PERMIT TO PERFORM ELEGTRIGAL, V
Ali work to be performed in Occordnnce 1vill7 the Mnssachusetts Electrical Code(NMC),527 CMR.12.00
(PEErlSE PRINT_0V1AW O PE INFOAALITIOA9 Date:
+City or To'm1 of: To the Inspector of Wi-es:
By this application the understgne givesn e his ocher intention to perform the electrical work described bt
Lacatiqn (Street&Number) C
Owner or'Tennnt Ci ! Telephone No_
Owner's Address
Is this permit in conjunction With u building permit? Yes ❑ No [ChecltAppropz-intet�
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overbead ❑ TJnd rd
g ❑ No. of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No. ormeters
Number of feeders and Ampocity.
Location and Nature of Proposed Electrical Woril: u t�
Cant Istlan afthe follarvin /able may be waR+ed by the I17s
No. ofRncessed Luminaires No.o£Ceil,-5usp.(Paddle)Fans No.of Tc
Transformers lc
No, or Luminaire Outlets No,of Not Tubs Ganerntors
Ira-
No.ofLuminnfres Swimming Pool Alcove � ❑ o.o 'me eney yt,ig inI
rnd. g r nd. Bette Unfts
No. ol{'Receptnele Outlets No.of Oil Burners FIRE ALARUS No, of
No. of Switches No.of Gas Burners No,of 13etection an
InitiatingDevices
No. of
Itnnges No.of AirCnnd. Total No.ofAlertingDevices
No. of Waste Disposers eatPuTop umber Tons It o,of eiC- ontatnecd
TotnLs; Detection/Alerting LDevices
No.of Disliwnshers SpacelAren$eating ZC4'Y Loeni❑ munic pal
Connectfora
No. of"Dryers Heating Appliances lib Seeurity5yystems:
o. 0.1 nter NO.of Devices or E uiv
Henters lav Plo. of No. of Data Wiring:
Si as Ballasts No,ofDeviccs or j, uiv
No.Ilydromnssage Bntbtubs No.OrMotors Total HP' Teler mmnnic[ll Winn
O'I'H]GIt: Na.ofDevices or aiv
Attach addYlarwl detail ffderlrer;or as required by t/le Jn.rp
Estimated Value of Electrical Wor1r. (When required bymunfcipal policy,}
Work to Start: inspections to be requested in accordance with MEC Rule 10,and upon compie
INSURANCC:CO• .LRAGEE:=Unless-wnived-hy-thwowner rio.pdtmit-for tIie=phi:fdrm'rtrice:af-�electilcnl•Work ma
the licensee provides proof oflinbillty Insurance including"completed operation"coverage or its substantial'equiv
undersigned certifies thatsuch cove is in force,and has exhibited proof ofs a tq the p itissuin oface_
CHECIC ONE: INSURANCE _ BOND ❑ OTHER ❑ (Specify.) b /
fear/ijtj rr•'rzTer`=tllepa7i panaft es-arperjii
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ITRI1� NAI1dE: tJ .�
LTC.K0..T7,
Licensee: Sr CJ� Signature __ LIC.1;I�.;
(IJapplicable r�'mnlpt"hi to license number line. Bus.Tel.Nu.Address: Ll Alt.Tel.No__f ;
`Per Tv i3.L,e. 14 s.57-6I,security work requires Department ofPublic Safety�'S"License: Lie.No. �U
ONVNER'S INSURANCU WAIVER: I arri aware that the Licensee does not have the liability insurance clave—
rag
required by law. By mysignature below,I hereby waive this requirement I am the(check one}❑awner
Owner/Agent ❑ 01
�-I Signature Telephone740.
� '• x,� Y7 P �a `i n v.
u
STEPHEN A JIM II'I 4
555 SAL:EM 5T
NORTH ANDOVER MA 01845-31'09:
Fold,Then Detach Along All Perforations
4NIMONiNEALTFt.OF_MSACHUST =:
Fill
fy Tw. arc j}jj"�.yy� �F* `N, }p y[ y■� y`�•.
}YV; 4+j �Il • tl.. OWfI-Nl in F't �'+rv+ f•: ,
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EP1EN M Juav,!i.t °
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17.
ORT, A 01845 31 C79
44,
II
GENERATOR APPLICATION
DATE:
LOCATION:
OWNERS NAME: ffztc, r�
GENERATOR kw ZZ
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR: JL) M
PHONE NUMBER:
ELECTRICAL nGAS
RESIDENTIAL COMMERCIAL TEMPORARY
LOCATION OF GENERATOR: 66, jeG �
TZONWGDISTRICT:
*CONSERVATION APPROVAL--� ��/-
AOL
The Commonwealth ofMassachusetts
Department of.1ndustrigl Acelde is
Office oflnvestigations
600 Washing-ton Street '
Boston,MA 02111
•www.massgov/dza
Wo rkexs' Compensation Jfusuran.ce Affidavit:I3ui dersfCo>ntraei-orsJElectxxezans/Pliiinbexq
;ADpliteant 7n orma ion Please Prim LegibZy
'Name(Business/Oxganization&dividual): JI) /c C:-
City/ t to/Z )Phone#:
A�/o,it an.employer?Check the appropriate box: Type o roject(required):
1., I m.a employer with �• ❑ I am a general contractor and I 6. New construction
employees Gull and/or part time).* have hired the sub-contractors
2.El I am a sole proprietor or partner- listed on the attached sheet. 7• [�Remodeling
. ship and'have no.employees These sub-contractors have 8. E]Demolition
working for me in any capacity. workers'comp.insurance. 9. [�Building addition
[No workers' comp.insurance 5. ❑ We are a corporagon and its 10.[]Electrical repairs or additions
required.] officers have exerelsed.their
3.El I am a homeowner Going all work right of exemption per MGL I L E]Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),andwehaveno 12.QRoofrepairs
insuxancere iced.]i employees.[Moworkexs'
ME]Other
comp.insurance required.]
Any applicantthat checks box#1 must also fill outthe section bel6w showingtheir workers'compensationpolicy information.
t'Horneownerswhosubmitthis affidavit indicatingthey9 doing allworKand then hire outside contractors must subailt a now affidavit indicating such.
tContractors that checkthis box must attached on additional sheet showingthe name ofthe sub-contractors andtheir workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for ray employees Below is the policy anrt job site
infarmation. i
Insurance Company Name% t ��� lC
Policy#ox Self ins.Lic.#: ?5 � o 71O.J Expiration.Date:
Sob Site Address:_ —City/State/Zip:
b (Ydlo�,
Attach a copy of the workers'compensatioupolicy declaration.page(showing the policy number and expiration.date).
Failure to secure covexago.as re%meduudox Section 25A ofMGL o.152 can load to the imposition of criminal penalties of a
fine up to$1,50 0.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER.and a fine
ofup to$250.00 a day against the violator. Be advised that a copy ofthis statementrnay be forwarded to the Office of
Investigations of the DU for insurance coverage verification.
X do iereby certi ill pa ncl nlaties of perjury that the infoYIY ationprovided ail ye 7 tt'lle and correct
Si mature: Date:
Phone 4:
ofjieial use o dy. .Do not write in this area,to be completed by city or town official;
City or Town: Permit/License 0
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/T'own Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other - -
Contact Person Phone#: