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Home My WebLink About- Permits #12374 - 105 HIGH STREET 5/21/2014 � . Date...A-./ aF''ORT",;°ti TOWN OF NORTH ANDOVER o? ' PERMIT FOR WIRING �9884CHU r d y This certifies that . ••• •• sio toperform A " has penvs a .. wiring in the building of.. rth A er M ndov ass H , A G at . .� ....... Fl pIII V ... ......... .......... ..........:, SPECfOR Fee•... ................Lic.No. ELECTRICAL IN Check# — Commonwealth of Massachusetts Official Use 0-1v Permit No. Department of Fire Services cupanc BOARD OF FIRE PREVENTION REGULATIONS [pevOc. iw]y and Fee Checked(leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Elate.- 2 City or Town of: NORTH ANDOVE,R To the Inspector of WlTres: 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 Telephone No. L 1 S ( ,�C,:,- 1!� IE� 2-1 I<',47C a(�L"A-r C.A Owner's Address �Ll 1".4 C-) Is this permit in"conjunction with a building permit? Yes M' No n (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps volts OverheadF] Undgrd n No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: jaWAtt I J (�A03 PAIN) l j Q (J56pletlon of the fallowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.o Total No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above o In- W07-OTEmergency Lighting grnd. grnd. 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 InitiatiaL,Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump ..........J.KW.......... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Mulllc'PP' El Other Connection I No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equiva ent No. of Water No.of No.of Data Wiring: Heaters KW 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. CBECK ONE: INSURANCE FA...........'I%ND 0 OTHER El (Specify:) I certify, tin der tl erjuiy,thal the information on this application is true and com te ai I enallies plete, ofp pCv90q FIRM NAMEr, LIC.NO. !5 � tj (VI Licensee: Signallre.... 0-&?,[A Bus.Tel.No.. NO.: (1fapplicable,ente "ex it"in the license number line) 07 . Address: ik&(44 A- 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)D owner D owrior'Lagent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts .Department of Industrial Accidents Office of Investigations IN 600 Washington Street Boston,MA. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Business/Or anizationlindividual C7-.. �r Address: .. OA � . 1 City/State/Zip: Phone#: �� .,` °� , 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 I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ l am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.(]Roof repairs insurance required.]t employees. [No workers' 1311 Other comp.insurance required.] *Any applicant that checks box#1 must also fill outthe section below showingtheir workers'compensation policy information. i Homeowners who submit this affidavit indicating they a"re doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer iliat is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:. Policy#or Self ins.Lic.#: Expiration Date: Job Site Address: V 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 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. ~ I do hereby c rttfy under the pains,fcnd penalties ofpei jury that the information provided above is true anti correct. - Signaturw �m . �� ...... Date: Phone e3 190,2 Official use only. Do not write in this area,to he 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 y Contact Person: Phone#: e > COMMONWEALTH OF MASSACHUS TTS � o ® ELECTRICIANS . ISSUES THE FOLLOWING LICENSE D AS R RG JOURNEYMAN ICIA J4},EL. .A WINSLOW iz Z I 4- AMBERWOOD DR J JoK:CNSON NH 03811 2208 j 35094E 07/31�16; 47955 f