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Home My WebLink About- Permits #12568-1 - 179 HAY MEADOW ROAD 8/10/2015 f o�ponrH,� r•`' °o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8��CHUg�S This certifies that ............. `...' r ......... : ................................. has permission to perform a.......e :.................... wiring in the building of 5 a ..�..:. '� ..�' .4.,',d�. at ......:.. .... ;s f r .��. � North Andover,Mass. I Fee...... .. Lic.No. .......... ELECTRICAL INSPECTOR Check# � i f Commonwealth of Massachusetts Official Use,Only F D Permit No.epartment of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o 7] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME.C),527 C 12.00 (PLEASE PRWTININIC OR TYPE ALL INFORMATION) Date:— 10 City or Town of: NORTH ANDOVEJ R To the Inspector of Wires: �I By this application the-undersigned gives noti 140 f his or her intention to ne' rn the electrcaworA desci,bed below. Location(Street&Number) h�,4 M Y Qu e 1 -79 Owner or Tenant TelephoneNo. \ 178- Owner's Address e J Is this permit in conjunction with a building permit? Yes Q/ No D (Check Appropriate Box) Purpose of Building -Utility Authorization No. Existing Service— Amps volts Overhead ❑ Undgrd[I No.of Meters New Service Amps Volts Overhead❑ Undgrd F1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingtable may be waived by the Inspector of Wires. No.of No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In- Ei N—o.of Emergency Lighting grnd. grnd Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo. of Zones of Detection and No.of Switches No.of Gas Burners No.Initiating Devices Tot No.of Ranges No.of Air Cond. Tonsal No.of Alerting Devices Heat Pump I Num ex Tons IKW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Munic*'P tPl n Other No.of Dishwashers Space/Area Heating KW Local❑El Connection No.of Dryers Heating Appliances KW SecNo.ourity f Syste vicesms:* De or uivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent__ Telecommunications Wiring: No.Hydromassage:Bathtubs No.of Motors Total HP No.of Devices or Eguivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 coyerage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND El OTHER F1 (Specify:) Icertify, under i pain ndpenalties ofpeiJurp.that the information on this application is true and complete, rg---7 FIRM NAME: CE W� LIC.NO.:,,'�i A Z Licensee: Signature LTC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.- Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,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)n owner E] owner's agent. Owner/Agent I PERMIT FEE: $5h— Signature Telephone No. The Commonwealth of.Massachusetts _ Department of IndustrialAccidents ~w 1 Congress Street,Suite 100 - d Boston,MA 02114-2017 ••- . �r. www mass.gov/ilia -1 a�M Sy'y9 Workers'Compensation Insuran ce Affidavit:Builders/Contractors/Electricians/Plumbexs. TO BE MED WITH THE PEI2IVQTTING AUTHORI X'. Please Print Legibly A �licant Information Name(Business/OrgabizationAndividual): Address: �' Phone#: City/State/Zip: :. .:. a.. Type of project(required); Are you an employer?Check 6c appropriate box: to esfr and/or parttie ` 7, p Newdonstr6don l.[ Iamaemployerwith em an 2.❑I am a sole proprietor or partnership and have no employees vvorking for mein 8. Remo deliiig any capacity.[No workers'comp.insurance required.] 9. ❑DemolitiOR 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.Fj I am a homeowner and will be,hiring contractors to conduct all work on my property. I will 11❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12��Plinnbing repay s or additions proprietors with no employees. I_ 5.Fj I am a general contractor and Ihave hired the sub-contractors listed onthe attached sheet. 11 Fj Roof repairs These sub-contractors have employees and have workers'comp.insurance t 14.Q Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] k Any applicant that checks box#1 must ajso fill outthe section below showing theirworkers'compensationpolicyinfonmation. i Homeowners who sribmit•this affidavit indicating they are gall work andthen hire outside contractors must submit anew afffdavit indicating such. tContractors that check this lions multi attachedan additional sheet showing the name of the sub-contractors and state whether of not those entit}es,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ,� .. •-- - X am an employer that is providingwor kegs'compensation insurance for°my employees. helow is the policy ancl)oh site information. Insurance Company Name: Expiration Date: Policy##or Self-ins.Lic.#: City/State/Zip: rob Site Address: omipeztsationpoIicy declaration page(showing the policy number and expiration date). Attach a copy of the workers' c Failure to secure coverage as required under MGL e.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties 0f InvOesgations of the DIA for insur5anc0 a day against the violator.A copy of this statement may be forwarded to the e o coverage verification. X do lierehy certify under tliepa:. and enalties of perjury that the information provided alcove is true and correct. Date' b Si ature: G Phone##: ite in this area,to he completed by city or t01Vn official Official use only. Do not wr l.Permit/License City or Town: ## issuing Authority(circle one): i 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: