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Home My WebLink About- Permits #12010 - 66 HAY MEADOW ROAD 11/18/2013 i i p 7 Date....... 9 ............... i TOWN OF NORTH ANDOVER PERMIT FOR WIRING �84CNUg� y it t . :... s.. This certifies that has pernussion to perform ............. I wiring in the building of............................. e q k . at 1 ........ ,North Andover,Mass. Fee`.:......:.. .u� ...,::�ram............ r:.�r.�::� ELECTRICAL INSPECTOR Check# I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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 PRINT ININK 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 her intention to pet-form the electrical work described below. Location(Street&Number)_ Owner or Tenant L, Ix (,k> Ix C�> L_ Telephone No. I/�,�, , — -5.)� - b�T/ Owner's Address 7 3 Is this permit in conjunction I, with a b mit? Yes F1 No (Check Appropriate Box) Purpose of Building ,� )�t Utility Authorization No. 1 921 5q S14 Existing Service ' Amps ?" / -e,(°, Volts Overhead F1 Undgrd R-_"" No.of Meters New Service — Amps Volts Overhead❑ UndgrdE] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �4 Conipletion ofthe ollowingtable nNy be waived by the Inspector qf Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.0 f Total QN� Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ in N—o.of Emergency Lighting rod. ,r.d. rl No.of Oil Burners FIRE i units y r No.of Receptacle Outlets 'I RE, ALARMS No.of Zones of D anT No.of Switches No.of Gas Burners No. Initiatinetection2 Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number .I Tons No.of Self-Contained Totals: ..... .... . Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal El Other io Connectn "I"Systems: No.of Dryers Heating Appliances KW Security��;EemsF No.of Water No.of No. f No.of Devices or Eguivalent Heaters KW Signs Bal o lasts Data Wiring: No.of Motors Total HP No.of Devices or Equivalent No.Hydromassage Bathtubs Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail ifdesired,or as required by the Inspector of 117ires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: -LO .-01] d 5 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. �t, � / " CHECKONE: INSURANCE BOND R OTHER n (Specify:) I certify,under the pains andpenalties ofpeijury,that the information on tion is FIRM NAME: (C.It, true and contlVete. Licensee: _110 7 LIC.NO.: (I'applicable, enter "exempt"in the license nuinber line) Address: Bus.Tel.No.-'_,� Alt.Tel.No.: *Per M.G.L c. 147,s.57- 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 0 owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of lndustrialAceWnts Office of Investigations 600 Washington Street .Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)::I. a . 1� Address: City/State/Zip: _ ; _ Phone#: q'I ] Are you an employer?Check the appropriate box: Type of project(required): 1. I a employer with 4• ❑ I am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. [_1 Demolition working for mein any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 1QEQ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.] employees. [No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tG?ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1/ LA��.@.�(4 p Policy#or Self-ins.Lie.#: (� 0 1 A Expiration Date: �� ' I ►.� Job Site Address: 1,2 o lJo-v r �J&U- 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 requiredunder Section 25A of MGL 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 against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo wider t 'ns and pen/alties o er,j that the information provided above is true and correct ' V / 1 Si afar : 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 Cleric 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: f - Fold,Then Detach Along All Perforations 4 dOMMONWEALTH OF Ma � HUSETTS re ® � BOARq O ELECTR"I C I ANS' ISSUES THE FOLLOWING LITCENSE AS A W REGISTEREb MASTER ELECTRICIAN a .. z DBA ' HARN ELECTRIC w i DANIEL N SCHARN Z Itu 115A BRIDLE RDA BILLER(CA >MA' 01821 1718 1 1101 "o