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Home My WebLink About- Permits #13094-1 - 20 HIGH WOOD WAY 2/8/2016 Date.2. k I Noarry 3� ; tiooL TOWN OF NORTH ANDOVER ° 9 PERMIT FOR WIRING • gswoausE This certifies that F ` �� v ........ .. . .................................................. has permission to perform �. s1 ..... ........ ......�� I wiring in the building of..............L � .. ....�`..P................................................................ ! s t $ f�: :...- North Andover,Mass. at 1 Fee Lic.No. � ELECTRICAL INSPECTOR Check# Comm nmoalth o/Mw6acAujelfi Official Use Only olJePartment o�Mire SB/U6c.6 Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [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)NFORMATION) Date: , �2 f City or Town of: _ , y cd y tJ�1; To the Inspector of Wires: By this application the undersigned gives notice of hi or her intention to perform the electrical work described below. Location(Street&Number) C> f 00,4 Owner or Tenant e u 19 ' ' Telephone No. Owner's Address 1 VIA � �r Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 1) t 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: rc �• v Com letion o the ollowin table may be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil.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 1 mergency 19 ng rnd. rnd. Blasa Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches .of Gas Burners No.of Detection and Initiatine Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons__ _ W NO.o Se f- ontained Totals: ... _...._.' Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW ecurity ystems:* No.o Water No.of Devices or E uivalent No.o No.of Heaters KW Data Wiring: Si ens Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wir,n OTHER: No.of Devices or Equivalent 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: µ( Je Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: 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 g undersigned certifies that such F rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEBOND ❑ OTHER ❑ (Specify:) ��1 re) I certify,under the pains and penalties of perjury,that the i rformation on t is application is true and complete. FIRM NAME: e U" _ LIC.NO.: 3 t /J� Licensee: Signature�n . - LIC.NO.: (If applicable,enter "ex t"i the license number line.) C I L$nS.Tel.NO.Address: �x ' 0*Per M.G.L.c. 147,s.57-61,security work requires epartmeblic Safeicen e: Alt.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 ner's agent. Signature Telephone No. 1PERMITFEE.- $ '' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El leetrieians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): LYe. e C) 7 a rl Address:_- z City/State/Zip: �.f 'L"tta /fits [�/�y� Phone#:v �7( ( K' Lf , Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 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. t 7• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity, workers'comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 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 12.0 Roof repairs insurance required.]t employees, tNo workers' 13.❑ Other comp. insurance required.] - — - `Any applicant that checks box#1 must also till 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. $Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self ins. Lie.#: p Expiration Date: �/ ,fob Site Address: / � � (rt.� City/State/Zip:�I—A 0 Cyr /��5 j Attach a copy of the workers' compensation policy declaration/page(showing the policy number and expiration date). Failure to secure coverage as required under Seetion 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 certify i der the pains and penalties of perjury that the information provided above is true and correct. Si ature: `✓ Phone#: �r5 .) 7- 5 J z/ Official use only. Do not write in this area,to be completed by city or town offaeial. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: 3 COMMONWEALTH OF MASSACHUSEM 801A t�F EtiTR!MANS ISSUES THE FOLLOWING 1:lCENSE S RAG>JOURN.EYMRN: ELEGTRIC;IA1�' J}1lES M LEONARD SR L W; 1 'DEXTER METHGEN MA 01844-54Y9''... .. $1 o7/311 64441