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Home My WebLink About- Permits #11454 - 29 HEATH ROAD 3/14/2013 Date „... NonrN TOWN OF NORTH ANDOVER PERMIT FOR WIRING �Oq+i�o•. ,(l �BgCHUg� This certifies that ............. 6..F::..` ..o 1: .'. .... ........................................... dl has permission to perform £ £- ....... ......... �.............>............. wiring in the building of t € .......................................... F- at ... �. ..... ,North Andover,Mass. ..........Lic. ...: F � ..................... ELEGTRICALINSPECTOR••j� ...•....... Check# -' ` , Commonwealth of Massachusetts 'dine'„"1,.Jse-only Department of Fire Services PermitNo. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NIEC),,,527 CMR 12.00 (PLEASE PRWT.ININK OR TYPE ALL INFORMATION) Date: t k4 _ City or Town of: NORTH ANDOVER To the Xnspecto f WiAs: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant M 1 c Q V,'^yr Telephone No. Owner's Address 61+\11 Is this permit in conjunction with a 411ding permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building &t1 St VCvv\. i "I 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 Proposed Electrical Work:-PA 00 - ii C JS Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No,of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA '. No,of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd, rnd. Battery 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 No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers HeatPump Number Tons KW No.of Self-Contained p Totals: ""' "' """""""'"""""""""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliancesr 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: INSURRANCE ❑ BOND ❑ OTHER ❑ (Specify:) Icertfy,under the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: yl Cr,�r-o, LTC.NO.: L1,1®'I Licensee: ccce Signature LIC.NO.: -a-oIGX0 A (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: 1, Address: l vv\& Q 15 0 Alt.Tel.No.:I / c-r-1'A('01 *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)❑owner ❑owner's agent. Owner/Agent PERMXT FEE: $ "� Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall belimited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass EN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH ECTION: Pass 1V Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: / Date: FINAL INSPECTION. Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massa is Department of Inditstrial Accidents office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia ce Affidavit:Builders/ContractorslEl Please Print Le bl Workers' Compensation Insuran Mi_ant Information pi me (Business/Organization/lndividual): .ddress: Phone#: ay/State/Zip: 'Type of project(required): Check the appropriate re you an employer• box: 4 ❑ I am a general contractor and I 6, ❑New construction I am a employer er with have hired the sub-contractors ❑Remodeling employees(full and/or Part-time).* listed on the attached sheet. 8 ❑Demolition I am a sole proprietor or partner- These sub-contractors have Building addition ship and have no employees workers' comp.insurance. 9. ❑ for me in any capacity. 5 ❑ We are a corporation and its 10[]Electrical repairs or additions working repairs or additions [No workers' comp.insurance officers have exercised their 11 ❑plumbing P required.] right of exemption per MGL Roof repairs ❑ I am a homeowner doing all work c.152,§1(,J),and we have no 12.❑ o workers' comp. employees.[No workers' 13,0 Other myself.[N , comp.insurance required.] insurance required.] ensation policy information. o such. their workers'comp olic information. licant that checks box#1 must also fill out below showing f the sub contractors and their workers'comp'p y a are doing all work and then noire outside contractors must submit a nevv affidavit indtca mn Any pp the name Ob Site Homeowners who submit this affidavit indicating g contractors that check this box must attached an additional sheet showing 'cont ensation insurance for my employees. Below is the policy and job to er that is providing workers p am an emp y 7formation. isurance Company Name: ExpirationDate: olicy#or Self-ins-Lic.#: City/State/Zip: the policy number and expiration date). -3b Site Address: policy declaration page(showing P Penalties of a compensation p Y imposition of criminal ,ttach a copy of the workers' comp ORDER and a fine 1 as civil penalties in the form of a STOP to OR he Office of as required under Section 25Ae1 f MGL c•152 can lead to the imp T ailure to secure coverage ear imprisonment,as w of this statement maybe forwarded ne up to$1,500.00 and/or one-year Cup to$250.00 a day against the violator. Be edverification.copy �vestigations of the DIA for insurance coverages o erjttry that the information provided above is true and correct, certify I'll the pains and penalt fp do Itereby ify Date: i nature: hone#: or to)vn official. official use only. Do not write in this area,to be completed by City se# PermitlLicen City or Town: Inspector (circle one): Cit /Town Cleric 4.Electrical Inspector 5.Plumbing P Issuing Authority( i Department 3. Y 1.Board of Health 2.Building P 6.other phone#: