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Home My WebLink About- Permits #13084 - 151 HILLSIDE ROAD 1/26/2015 Date ............... OtjORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU ..........This certifies that ........................................................ ................................................ has pennission to perforra ... ............. ......... .......... ...................... wiring in the building of ............................................... ............................................................. at .... ..................................................................................................North Andover,Mass. Fee r.......... .................Lic, No. .......... ........... ELECTRICAL INSPECTOR Check# V Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. I BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (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: J 7 s City or Town of: '/ �� 7;f✓j To the Inspector of Wires: By this application the undersigned gives not'ce of his or her intention to perform the electrical work described below. Location (Street& Number) ICJ/ P JJ 5 j d g_ tC t� Map: Lot: Owner or Tenant 'lJY!(3� C�i�G�A�t� _ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes D� No ❑ Building Permit# 3� Purpose of Building 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: IYC' j F f l,M l L - Completion of the following table may be ivaived by the In ector of ff'ires. No. of Recessed Fixtures No. of Ceil:Susp.(Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA Above In No. of Emergency Lighting No. of Lighting Fixtures Swimming Pool rnd. ❑ rnd. ❑ Battery Units No. of`Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No.of Waste Disposers Heat Pump I Number I Tons JKW No. of Self-Contained Totals: I I 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[Fires. 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:) (Expiration Date) Estimated Value of Electrical Work: q t)C)C� (When required by municipal policy.) Work to Start: "-171r) ` Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains antipenalties ofpe►juty,that the information on this application is true and complete. FIRM NAME: li�IS ALP /i L'_ Cl/1� � LIC. NOA/`7 369 Licensee: I CC rcc"0 4)/015 _ Signature --' �( �� - �� LIC. NO: (If applicable,Q7ter "eaent t"in he Bus.Tel. No 75%-3Vn�Address ke,,4 �1(rC) Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I ani aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. P/All The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 1 Corzgr-ess Street, Suite 100 µ.. r. Boston, MA 02114-2017 ^. =.> wrvw.mtrss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): finis Electric Inc. Address: PO Box 3955 City/State/Zip: Peabody MA 01960 Phone #: 978-531-4471 Are you an employer? Check the appropriate box: Type of project(required): 1.❑- I am a employer with 7 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and Have no employees These sub-contractors have Q, ❑ Demolition workingfor me in an capacity. employees and have workers' Y9. � 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 I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] If c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant Chat checks box 41 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. I am an employer that is providing workers'compensation insurance for my employees. Belo iv is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Policy# or Self-ins. Lic. #:WC3918369 Expiration Date:August 2015 Job Site Address:-�S� .ocSti0 P- 10 City/State/Zip: 6(", 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 certify under the pains and penalties of'perjury that the information provided above is true and correct. Signature: �� Date: r""ry Phone#: 9785314471 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#: Or OHOS :.-,"4 •OMMO 1I TM.Of M BE ;.t`> ul SSUES �.H. a< OLLOW LECTR I <:;.... E. T'r'k D MAST�R�: ` nn=<t..•jjj(��. •ELECTRIC j"N'C`.. 3955 �, 61 ., 1730 'A 019_ ' { • • '• • _ • is ( I A� I SSU FOLLUW I%:OWL fCE O,URNEY v ELECTRVCI AND M.DAM-11 •.LPL � `I•• �� 1 ��- . i