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Home My WebLink About- Permits #13220-1 - 50 HIGH STREET 3/25/2016 Date. .............. .......... OF NORT{�,� TOWN OF NORTH ANDOVER o _ J , PERMIT FOR WIRING '88"1CHU5�� q F This certifies that ,,.. -- has permission to perform .A � i °'`� ��- wiring in the building of.............................:°�:........ at ,,,�; .. ... .. 5..................................,North Andover,Mass. Fee _ �o ...R....Lic. N .�. ................................................................................... ELECTRICAL INSPECTOR Check# 4-\ Commonwealth Of Massachusetts Official Use Only Department Of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �_0 �_�K)t K� City or Town of: NORTH 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. Location(Street&Number) ( c Owner or Tenant L Cc,vV1 Telephone No. Owner's Address Q L n ov-C, M f Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building (:2 (wp c _ 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: J. '� r Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o,o mergency -1g ing rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No. InDetection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number To KW No.o Self-Contained .... .... . .............. ...................... Totals: Detection/Alerting Devicesal No.of Dishwashers Space/Area Heating KW Local❑ Con ici lion ❑ Otherct 4 No.of Dryers Heating Appliances KW Security Systems:* � No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ; C06 (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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: _ K-A Z.-1— L LIC.NO.: .:211 t� — Signatures LIC.NO.:C Li(),Lt t) (If applicab e,eater "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) owner ❑ owner's a ent. Owner/Agent Signature Telephone No. FPERMIT FEE: $ The Commonwealth of Massachusetts Department of'IndustrialAccidents Office af'Investigatians .1 Congress Street, Suite.100 ` Boston,MA 02114-2017 wrvw mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I.,egib Name (Business/Organization/Individual): A2 Systems, LLC Address: 100 TradeCenter Suite G-700 City/State/Zip:Woburn, MA 01801 Phone #: 855-438-7101 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 7 4. C] I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity, employees and have workers' Y9. L] Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ® We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.C] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other Security System employees. [No workers' comp. insurance required.] `Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Crum & Forster Policy#or Self-ins. Lic. #:4087280313 Expiration Date:2/20/2017 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 required under Section 25A of MGL c. 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 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. do hereby the pains and penalties of'perjury that the information provided above is true and correct. certify c fy under Si naturd. .� C"._' G_.._�..�,>,_.._---....,-.�_._.. �,.,._. vlc// ...._ Date: Phone#: 9789954859 C7( '► �' ��P,�)-er— Offr"cial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Pelson: Phone#: OM OF menMASSAC F/(Js '�Bo ISSUES ELECel TNE: FOLL ANS RFO.►STERED OWING 'L'_►CENS SYSTEM: E AS:._ Al SYSTEMS L L c CQNTRA C7'OR . R1CK CONNORS.: 50 W►MBLEbpN z X►MG WRAC 8 MA► a►8 4� a ► 6 6320: _ 186 ..COMMONWEALTH OF MASSAtCHUSETT:S Iff `ELECTa'l CI ANS ISSUES,: THE FOL10t�lNG ..LICENSE AS A RC1.5TERED SYSTEM TECHNICIAN' m �PATRI'CK CONNORS a 3W „ 50 WIMP " OON X I N'G o DRACUT MA a1826-6320 2424 D 07/31/16 64348