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Home My WebLink About- Permits #13097-1 - 147 HIGH STREET 2/9/2016 Date.....::............... ............. k O�p�ORTOY 4� 3i ; ooL TOWN OF NORTH ANDOVER p PERMIT FOR WIRING '$QACHU a This certifies that . � has permission to perform ��a� 1........ ......... . ....::.. 0 wiring in the building of,.,..,, (. ... at � d ._ North Andover Mass. ............ ......................,.... ..... , Fee .......Lic. No . � k ELECTRICAL INSPECTOR Check# 76 r / ?t Commonwealth of Massachusetts Official Use Only Department of Fire Services permit No. ( 11 �' I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 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: 2/8/16 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) 147 HIGH STREET Owner or Tenant ROBIN MORGASEN Telephone No. 978-828-2892 Owner's Address SAME `) Is this permit in conjunction with a building permit? Yes X No El BLDG PERMIT# Purpose of Building SINGLE FAMILY Utility Authorization No. 21256893 Existing Service 100 Amps 120/240 Volts Overhead❑X Undgrd❑ No.of Meters 1 New Service 100 Amps 120/240 Volts Overhead❑X Undgrd❑ No.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CHANGE SERVICE,BASEMENT BUILD OUT Completion of the ollowin table inay be waived by the Ins eclor o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total 12 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA 23 No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting 23 grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 20 No.of Switches No.of Gas Burners No.of Detection and 10 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump INTYer Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other 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: $7,000.00 (When required by municipal policy.) Work to Start: 2/8/16 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C n ess waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjary,that the information on this application is true and complete. FIRM NAME: MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON,INC LIC.NO.: A10421 Licensee: MICHAEL KELLER Signature LIC.NO.: E25006 (Ifapplicable,enter "exempt' in the license numberline) Bus.Tel.No.: 603-394-0117 Address: 27 WOODMAN ROAD,SOUTH HAMPTON,NH 0382 Alt.Tel.No.: 603-231-6068 *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License LIC.NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signa- ture below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. �\ Owner/Agent PERMIT FEE.,$ //L) Signature Telephone No. �/ u z �iJ 70 �"Px The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations "r r' 600 Washington Street Boston, MA 02111 tivww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 7�.7alrl(:(Business/Organization/Individual): MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON, INC. 1V Address: 27 WOODMAN ROAD City/State/Zip: SOUTH HAMPTON, NH 03827 Phone#: 603-231-6068 Are you an employer?Check the appropriate box: Type of project(required) 1.0 1 am a employer with 2 4. n I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp, insurance comp. insurance.t required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l,n 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 employees. [No workers' 13.0 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 are 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. lam an employer that is providing workers'compensation insurance for►ray employees. Below is the policy and job site information. TRAVELERS Insurance Company Name: — Policy#or Self-ins.Lic.#:INUB-0008592-9-15 Expiration Date:7/16/2016 Job Site Address:147 High Street City/State/Zip:N Andover, MA 01845 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 da hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: "`� " ,�"- - Date: 2/8/16 Pho e#: 60 -231.606 Official 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 Cleric 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: I s COMMONWEALTH OF MASSACHUSE7 TS BOA�fD C3E ELECTRICIANS ISSUES THE FOLLOW I NO L1'CEN. E X AS {k `RED JOURNEYMAN :f LEC,TRI CRN � MF�HAEL D KELLER �O 27 WOODMAN""RD Z' W i SO HAME''TON NH 0 82 — �Q'6 `{' r zSoo6..E 07/31:/16 8.675 �� iaaaiu,rnaa6 �.iais/_i�[eh�®Yid ��'TI • i " A