HomeMy WebLinkAbout- Permits #12729 - 57 HEPATICA DRIVE 9/9/2014 4
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oG TOWN OF NORTH ANDOVER
to PERMIT FOR WIRING
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This'certifies that ............ €
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has permission to perform1,1 •••
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-wiring in the building of ... ,•' + ............................................
4 ... orth Andover Mass.
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Fee d..... .................Lic.No. ....°........... ....... .... 3�, �. .... c..
ELECTRICAL INSPECTOR /
Check# OIL �.
(foinnwntueafik ol Vlai3alkaJeffi Official Use Only
Permit No. 1"" .—
2apartm-ent of Jim Servicej occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev, 1/07] (lav,bla,k)
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APPLICATION OR PERMIT TO PERFORM ELECTRIC-PtL WORK
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All work to be perfF ormed in accordance with the Massachusetts Electrical Code 12
ME 7 CM
Date:
(PLEASE PRINT IN INK OR ALL IN 0 A TION)�j C 0 fires:
City or Town of: X9 , k�00 J4 To the Inspec r of
By this application the undersigned gives notice of his()It her intention to perform the elect cal wo k described below.
Location(Street&Nurn�ber) Ae-
Owner or Tenant Telephone
Owner's Address
Is this permit in conjunctiM With a building permit? Yes ❑ No C8� (Check Appropriate Box)
Purpose of Building
'5c ��.:52Z> 2— Utility Authorization No.
/ -�
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps Volts OverheadF-1 Undard ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion pf'the,following table may be waived by the Inspector of Wires.
0.01 Total
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers— KVA
No.of Luminaire Outlets No.of Hot Tubs Generators 10 t1lia
Ka
Above F7 M
No.of Luminaires Swimming Pool or ❑ nits
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Detection and
No.of Switches No.of Gas Burners Initiatina Devices
---Total
Na.of Ranges Na.of Air Cond. Tons t,No.of Alerting Devices
—
No.of Waste Disposers
Reat Purnp I Number I Tons 1<W No.of Self-Contained
Totals:I DetectionlAler.tina Devices
No.of Dishwashers Space/Area Heating I(W Local F] Mu C'W F� Other
Con ection
Heating Appliances KW Security Systems:":
No.of Dryers n No.of Devices or..E uivalent
No.of Water No. of No.of Data Wiring:
Heaters KW Sions Ballasts No.of Devices or Equivalent
elecommunications Wirina:
No. Hydromassage Bathtubs No. of Motors Total HP uivAent
No.of Devices or Eg
OTHER:
_Attach additional detail if desired,at,as required by the Inspector of Prires,
required
y munic
ipal
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 cover�ge is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E2/ BOND D OTHER D (Specify;)
I certify, under the pains and penalties of perjury,that the information on this application is trite and complete,
LIC.NO.:Al
FIRM NAME: 5j�!c tl
Licensee: t ti' � �r° LIC.NO.:
(If applicable, enter "exei s.Tel.No.-
Address: / Alt.Tel.
*Per M.G.L.c. 147,s. License: Lic.NO. 55i
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)R owner R owners agent.
Owner/Agent
Signature Telephone No. PEKVIT FEE: S 7
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The Commonwealth of Massachusetts
Department of, ndustrlalAccidents
97 i Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
iv)vmniass.gov1dia
Workers' Compensation Insurance Affidavit: Build ers/Con tracto i-s/El ec ti-icians/Plumb e rs
Applicant Information Please Print Legibly
Name (Business/Organization/individual): SPEED WIRE INC
Address: 1750 N FLORIDA MANGO RD SUITE #106
City/State/Zip:WEST PALM BEACH Phone #:561 254-8610
Are you an employer? Check the appropriate box: Type of project(required):
1.NO I am a employer with 10 4. [] I am a general contractor and 1 6. F-I Now construction
employees (full and/or part-time) have hired the sub-contractors
2.El I am a sole proprietor or partner- listed on the attached sheet, 7. F1 Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for tile in any capacity. employees and have workers' 9. F-1 Building addition
[No workers' comp. insurance comp. insurance,T
required.] 5. 0 We are a corporation and its 10.7 Electrical repairs or additions
3 I am a homeowner doing all work officers have exercised their I LD Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.E1 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.IN-] Other BURGLAR ALARM
comp, insurance required.]
*Any applicant that checks box 9 1 must also rill 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
enlploy6S. If the sub-contractors have employees,they must provide their %vork-ers'cornp.policy number.
I(inzeiiieitiployei-tliati.vpi,os)ltliit,-ivoi-A-ei-,v'cot7ipensatioiiiiisui,aiieefoi-iitileiiiployet-,s. Below is the polig ane1job site
inforniation.
Insurance Company Name:LOCKTON COMPANIES LLC
Policy# or Self-ins. Lic. #:C4793820A Expiration Date: 10-01-2014
Job Site Address: ALL LOCATIONS City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine Lip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOR_1S.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 DIA for insurance coverage verification.
I elo hereby certify the pains anal penalties of perjury that the infonnation proville(I aho e s,truer id correct.
Si�l�ature: Date:
Phone#: z
Official use wily. Do not write in this area,to be completed by city or town offlIcIaL
City or Town: Permit/License 4
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#:
Ift Corn monvealth of 'Ik3ssachusetts '
Department of Public Safety
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