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Home My WebLink About- Permits #13136-1 - 105 HILLSIDE ROAD 2/24/2016 Date,G" ... ... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �ACHus� This certifies that ....... � fi ... ° ...I. ... has permission to perform .................:`. _� ''�-... ...`. "...................f.. ............................................ wiring in the building of. .�r ....: ..... .................................North Andover,Mass. .... Fee.. - .,.... Lic.Nc ... �:. :' .................................................................................... ELECTRICAL INSPECTOR /� 4 Check# � N i, I Commonwealth ®f Massachusetts Official Use Only Department Fire services Permit No. Occupancy and Fee Checked aM Ji. BOARD OF FIRE PREVENTION REGULATIONS [R.ev.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 PRINT ININK OR TYPE ALL MOR MTI0N) Date: Z;2 y 1 46 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) 1615— ///,/40 e Owner or Tenant r1/)+ Cr2 r o Telephone No. 9J:s' -- 7,0/ Owner's Address /61,5_%fi%%s//)e_ ,�� v Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of B 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: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-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- ❑ NO.o mergency Lighting rnd. rnd. 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 Initiating Devices No. of Ran es No.of Air Cond. Total No,of Alerting Devices g Tons No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:Y 3' No.of Devices or E uivalent No. of Water KW No.of No.of Data Wiring: I\ Heaters Signs Ballasts No.of Devices or Equivalent �b dromassa e Bathtubs No.of Motors Total IV Telecommunications Wiring: No.H y g 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: 2 I 16 _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 thepains andpenalties ofperjuiy,that the information on this app ' ion is true and complete. FIRM NAME: LIC.NO.: Licensee: Signature LTC.NO.: (If applicable,unter "exec pt"in the-license nu ber It g) Bus.Tel.No.: fh®3`f 7?o Address: /� � ��9YS%C'+¢� P� 03152 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 agent. Owner/Agent PEtZMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts f Department oflndustrialAccidents I Congress Street, Suite 100 tl Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. _Applicant Information Please Print Legibly Name(Business/Organization4ndividual): rUu2�/ Address: City/State/Zip:. to t'��`E' "I l Phone#: (90 2�D —Y Are you an employer?Checkthe appropriate box: Type of project(required): L❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. �l am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 F1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ �� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] G� e z / j�' *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit Us a�davit 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. fain an employer tliat is pfoviding worlrets'compensation insurance for•my employees.'Beloiv is the policy and job site information. Insurance Company Name: c4 y Vd ul u — Policy#or Self-ins,Lie.#: Expiration Date: Job Site Address:- LI)5- / City/State/Zip:IV,A AU`O() (3P Ilt-14 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Idoherebycerti undes`tliepa sandpe tiesofperjurythattheitformutionprovidedabove�i truea dcorrect. Signature:_ Date: OZ/ y Phone# 4 - ` 0 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: { - t � � AL7"y C F MASS L�tJAUS A ''� ' J(31lCly N .1 1 BEN' f"AN ELEG�I�.I.CI, W' f el fjj .. t rj E