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HomeMy WebLinkAbout- Permits #12142 - 225 HAY MEADOW ROAD 2/4/2014 Date.......�! ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING �I-U C U ............. ............................. ............................. This certifies that ..... ........................ has permission to perform ...... .......*"****"**"*................................... wiring in the building Of a.k................................................................................ .......... Andover,Mass. ...,-North ......................................... 12 at ................................... ...... .......... Lic.No - , I . ................... Fee,,.2.2................ ........ .... EL$CTRICAL INSPECTOR C-7 K CheckV J o_ Commonwea&o f Mamac4uaelb Official Use Only Apartment o/,}ire Service.4 Permit No. I T114 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1107] (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 y (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / 2 6 r /� r City or Town of: 14'6 rA Andover— To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. C „ Location(Street&Number) `"�`v` 5 M V 1©6J 16 0,,l C( Owner or Tenant p C e �— Telephone No. Owner's Address 76 Is this permit in conjunction Wip a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building V�)�G'tlC(�, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Pro osed Electrical Work: I/�G57 1 r- re IAJ Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Rot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- EJ o.o mergency Lighting rnd. grnd. BatteEy Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones - No.of Switches No.of Gas Burners No.of Detection and Initiating Devices r4 No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons � No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "'' '"""""''"'"' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: .-- No.of Devices or E uivalent (® OTHER: i 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: C©1W I _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 s undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) �S �` ^cry I certify,under thepains and penalties ofperjt�ry that the information this application is true and�omplete., FIRM NAME: � f ewo es LIC.NO.: l!- f f 9 Licensee: Signature LIC.NO.: (If applicable,enter "exempt"in the license number fine.) Bus.Tel.No.: Address: 1 ��e� . 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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of-iVMassachusetts - Department of IndustrlalAcc!6e is Office of Investigations 600 Washington Street Boston,.1t2A 02111 www.mass,gov/clza Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): Address: ��-(�x �v�" City/Stake/Zip: & I�('C�/ 4 Q��f�7Phone#: Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor and 1 6. .❑New construction employees(full and/or part-time).* have hiredthe sub-contractors 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. ❑Demolition worldng for me in any capacity, workers' comp.insurance. 9• ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No worker s' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs ilsurance required.]i 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. 1'Homeovtners who submit this affidavit indicating they 97re doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self ins.MG.#: Expiration Date: Job Site Address: 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 o.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. X do Hereby cert�u er the pains andpe alties ofperjury that the information provided above is true and correct. - Si ature: d i Date: Phone#: f official use only. Do not write in this area,to be completed by city or town offrcial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 9.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: GOMMONWEALT �OFXS . E:LECTRICIAIUS r : . SSUES THE FOLLOW I SIG L C'CENSv AS A .,RAG °JOURNEYMAN. ELECTft{C I - w I ; ,�A�4ES M LE0NARII SR 1 DEX7ER :ST METHUEN t�A 01844 541 g _ 381 g7.'E... ..: 07/3;�l 16 64441