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Home My WebLink About- Permits - 255 HAY MEADOW ROAD 2/10/2015 Date 0 i 4 O�p►ORTH 3r.• °o TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING �98gACHUg�4 � 1 This certifies that ..... :...��.... e �. d f q f b 4 has permission to perform .••• iC v E ....................................... wiring in the building of •• _ C ,N Andover,Mass. at .. . ,4, i r ) ` a Lic No ="" . -L... .......... . ...y Fee................ •...... ................. ELECTRICAL INSPECTO F Check# � � � • r �� ri - t t �. _ Common Official Use Onlywealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. i/07j (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be,perforined in accordance with the Massachusetts Electrical Code(14EC) 527 CMR 12.00 (PLEASE JoNNTININK OR TYTE ALL MFON11A TION) Date: JM7,2/s- City or Town of: NORTH ANDOVE'R 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) m Api Ao./)&J,i,,d Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes N--" No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead F] Undgrd[:1 No.of Meters New Service Amps Volts overheadE] Undgrd F1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electric Work: � Y Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No. of Total Transformers KVA I' VA of Luminaire Outlets No.of Hot Tubs Generators VA No.of Luminaires Swimming Pool Above ❑ In- El N—O.—OTE mergency Lighting grnd. grnd. Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones No. of Switches No.of Gas Burners No.of Detection and Total Initiating Devices No. of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump KW No.of Self-Contained No. of Waste Disposers Totals: Number I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal Fj Other I 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 Equivalent 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R`-BONDE] OTHER F] (Specify:) I certify, under the pains and pen allies ofperjury,that the information on this application is true and complete. FIRM NAME. LTC.NO.: Licensee: R,.)yA C`kf' j SignatureAz,2 LIC.NO.: A (If applicable,g,ter "exempt" e s number line.) Bus.Tel.No. u Address: j 0 1 Alt.Tel.No. *Per M.G.L c. 147,s.57-61,security work Oquires 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)D owner n owner's�agen�t Owner/Agent 155 Signature Telephone No. P umT FEE: The Commonwealth qf.1VMassachusetts - Depa�t�nent o,�'Incl~i'cst�irzlAccielents Office of Invesfigations 600 Washington Street .Boston,MA 02111 www.mass govIdla Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrliexansll'l a hers ApplIcaant Wornmtion Please Print Leaitbiy •Name(Business/Organization&divldual): , i', Ceti i Address: �iV��v� c�✓ OV). City/State/Zip: fi� k1 Jan A�Z, Of Phone#: ))8:j i V'6-fit y Are an employer?Check the appropriate box: 'Type of project(required): , I.►�"I am a employer with 4. ❑ x am a general contractor and I 6, JJ Now construction employees(full and/or part time).* have hiredtho sub-contractors 2,[] I am a sole proprietor or partner listed on the attached sheet. 7. [l Remodeling ship and`have no.employees 'these sub-contractors have S. []Demolition working forme in any capacity. workers'comp.insurance, 9. ❑Building addition [No workers' comp.insurance 5. ❑ We axe a corporation and its 10.❑Electrical repairs or additions required.] officers have exemised.their 3'[( Z am a homeowner doing all work right of exemption per MOL 11.�]Plumbing repairs or additions Myself.[No workers' comp. c.152,§1(4),andwehavono 12,Q Roofrepairs nsurancere fired i employees.[No workers' . � .a 13.El other comp,insurance required.] x.Any applicantihat checks bDx#f mustalso fill outthe section belowshowingtheirworkers'compensationpolicy information. t'Homeowners who submitihis affidavitindicatingthey 9 doing allworlc and thenhire outside contractors must submit anew affidavit indicating such. �Contraotors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an em toyer that ispvovlding workers'compensation insurance for my employees Below is the policy acid f oh site irafoxxmation. Insurance Company Name:- Policy#or Set-ins.X.,ic.#: Expiration 1)ate: lob Site Address: rCity/State/Zip: .Attach,a copy of0e,workers'compensatiowpolicy declaration,page(showing the policy number and expiration elate). Yailuro to secure coverage,as requiredundex Section 25A ofMGL 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 WORD ORDER.and a fine ofup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA.for insurance coverage verification. X do hereby cart' under•the a' s and venaltles of peryury treat ilte information provided a ove s true and eorreet, Signature: r Date: //6 �s Official use only. Do not write in this area,to he completerlliy city or toWrz official City or Town: Per mMieense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tovm Clerk, 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Division of Professional Licensure: License Search Page I of I The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass,Gov Home State Agencies A-Z Topics Home)Division of Professional Licensure> ONLINE SERVICES .................... ............................. ............ ......................... ............ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name: KEVIN WADDINGTON REFERENCES& HAVERHILL,MA RELATED INFO NEW SEARCH I Disclaimer Regarding Website License Searches Licensing Board: ELECTRICIANS Glossary of License Status Codes License Type:ype: JOURNEYMAN ELECTRICIAN TYPE CLASS: E More... License Number: 31685 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 1/25/1988 Exam Date: 12/5/1987 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday,February 10,2015 at 12:33:27 PM. 0 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http:Hlicense.reg.state.ma.us/public/pubLicensel),asp?board—code=EL&type—Class=—E&I i... 2/10/2015