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Home My WebLink About- Permits #11931 - 30 HEATH ROAD 10/15/2013 Date........P..............: ............... NOAr ;� ?e`_ : .'• °o� TOWN OF NORTH ANDOVER m PERMIT FOR WIRING + s •;rw *3',8°+.;.off•.tad 81CHUgE This certifies that .g[' � .Vf has permission to perform w a . r � wiring in the building of.... „r—i Jr `�, ..................................................................... at .... � ., �._ . .. ` n . orth Andover, ass. ...... .... ....... F Fee Lic.No.(,. EL C SPECT R Check# 0 a jG: gr Wit ' ` F Commonwealth of Massachusetts Official Use Only Department of Fire Semces Permit Na 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(MEC),527 CMR 12.00 (PLEASE PRTNTINNIC OR TYPEALLMFORMATION) Date: lo i ls"I e o City or Town of: NORTH ANDOVER To the Inspector f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) -N- :) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building s I", ,Q- �-,Cry,\, I I Utility Authorization No. Existing Service Amps volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps Volts Overhead n UndgrdE:1 No.of Meters Number of Feeders and Ampacity N Location and Nature of Proposed Electrical Work: A- e V\ A- Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No. o Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In- ❑ N—o,-oifEmergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets t No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burners No. of Detection and Initiating Devices No.of Air Cond. Total No.of Alerting Devices No. of Ranges Tons Heat Pump ..........I.KWI No.of Self-Contained ............ No. of Waste Disposers Totals: Detection/Alerting Devices Space/Area Heating KW Local El Mun'c'PP1 F1 Other No.of Dishwashers Connection Security Systems:* No.of Dryers Heating Appliances I(W No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Telecommunications Wiring: Hydromassage Bathtubs No.of Motors Total I-W No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as reqtdred 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 MMC Rule 10,and upon completion. INSURANCE COVER—AGE: 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. Theme undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. cBEcK ONE: wsul�-A-NcE FK1 BOND [I OTHER D (Specify:) IN, .1 certify, under the pains and penalties ofp ejury,that the information on this application is true and complete, FIRM NAME: LIC,NO.: ), ,O" ) A' Licensee: Signature �LTC.NO Y�04, ffapplicabie-,enter "exempt"in the license number line) Bus.Tel.No.. Address: I Q i-c-1 0 c)(4) 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)0 owner n owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ❑ 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 shalt be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited 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 R—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: 'french Inspection Pass R Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH S CTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Co ents: Inspectors Signature: Date: FINAL,INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetis Departmint ofIndustriqlAccWhts Office of Investigations 600 Washington Street Boston,MA 02111 vww mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Lej�bl Namo(Businoss/Organizationgndividual): Address: �kA, &Cej city/state/zip: czX�04"'JS, c, �CjQ(, Phone CY)) Are you an employer?Check the appropriate box: Typo of project(required): 1.0 1 am a employer with ,-( 4. 0 1 am a general contractor and 1 6. E]Now construction employees(Rill and/or part-time).* have hired the sub-contractors 7. []Remodeling 2.El I am a soleproprictor or partner- listed on the attached shoot.� ship and'have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers' comp.insurance 5. El We are a corporation and its io.FlElectrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MOL I Ln Plumbing repairs or additions myself.[No workers'comp, c. 152,§1(4),and we have no 12.El Roof repairs insurance required.]i employees.[No workers' Un 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 ere doing all work and then hire outside contractors must submit anew affidavit indicating such, tContraotors that checktbis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurancefor my employees. Below Is thepolicy andjoh site information. Insurance Company Name: CO�vNf"" Q_ Policy#or S elf-ins.Lie. Expiration Date: 0 CM..' . Job Site Address: 3Q) V. V 2- D- pity/State/zip: Vgl Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). FAilure to secure coverage as required-under Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a Me up to$1,500.00 and/or onc=yoar imprisonment,as wellas 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 may be forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. Idoherchycert! "der the pains and penalties ofperjury that the information provided above Is true and correct, \J Date: Phone#: 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.13uilding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: