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Home My WebLink About- Permits #12586-1 - 51 HAY MEADOW ROAD 8/17/2015 r . Date....... , .`.. . �µOR7Iy ,�?••+ ti°o� TOWN OF NORTH ANDOVER O tp PERMIT FOR WIRING ,83®CHU 7 This certifies that ...... ...........�. ............................... has permission to perform •....... � s'........... d , i wiring in the buildingof i t� �........... !.... ... ............................................. I at ..............v4........... ....t ` ......>Noip dover,Mass. Lief A Fee No. . �� .. ..... . ..........................I............................ a ELECTRICAL INSPECTOR iCheck# 7 Print Form—] ewynnonwea&of Mamac4welb Permit No. Official Use Only �VO�0, 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 CMR 12.00 (PLEASE SE PRINT IN INK OR TYPE,ALL INFORMATION) Date:— City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owneroi-Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead [:1 UndgrdF—J No.of Meters New Service Amps Volts Overhead ❑ UndgrdE] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7 Conipleflon qf the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil�Susp.(Paddle)Fans No.o Total y Transformers ICVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In- ❑ 0-of Emergency Lighting . grnd. grud. atteKy Units No.of Receptacle Outlets No.of Oil Burners IMF ALARMS INo.of Zones No.of Switches J-� 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 Pum is... [KW No.of Self-Contained Totals:p ........... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal 1 n Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total UP communicatio OTHER: Attach additional detail ifdesired,or as required by the Inspector of P11ires. 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Ml' . BOND n OTHER n (Specify:) I certify,under the pains and penalties of perjury,that the information oil is PPI* ation is true and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature— LIC.NO.: 14963 (Ifapplicable,enter "exertipt"in the license number line) Address: 87 BELMONT ST, NORTH ANDOVER, MA 01845 IY Bus.Tel.No.;978-682-6262 Alt.Tel.No.:978-375-5734 *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)n owner 11 owner's agent. Owner/Agent Signature Telephone No. J.PEJW1TFEE,.- $ �'1 '� The Commonwealth of Massachusetts Department of IndustrialAccitlents Office Of IrZVeStrgatror2S 4 I Congress Street, Suite 100 „ "�� Boston,MA 02114-2017 www mass.govAlia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address:87 BELMONT ST City/State/Zip:NORTH ANDOVER, MA 01845 phone#: 978-682-6262 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ 1 am a employer with 8 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑RestaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. n Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity_ [No workers' comp. insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have I0.❑ Manufacturing no employees. [No workers' comp, insurance required]"* I I.n Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12 they ELECTRICAL CONTACTING "Any applicant that checks box#1 must also fill out the section below showing thew workers'compensation policy information. "If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should clieck box#1. I am ari employer tlzat is pr-ovidirzg workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy# or Self-ins. Lie, # 9353694 Expiration Date:MARCH 1, 2015 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 MGI,c. 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 againstA violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fo m anc coverage verification. I do hereby certify, undMl '�' r rlpenalties ofperjury that the information provided bov 'is true and correct. 7 Signature: Date: Phone#: � 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.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia