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Home My WebLink About- Permits - 19 HOLLY RIDGE ROAD 10/22/2014 All Date 0 L OF N�RT�y, CL TOw .....�...................... i 0 m N OF aPER +� MIT Fo WIRING p This certifies thathas p rmissi .. e on to perform d< I .. ..... f q j wiring in the building ::` N. of -I , .......... I at ° � 1 a. �H I Fee � E xr•• ........ ... Lic.No. `I=pAndover, ••-• � � ��t-� h M ' • �Jass j' Check x ELECTRICAL SPECTOR 1 i Commonwealth of Massachusetts Official Use Only Permit No. ' Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS IROV- 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code Q,521 CMR 12.00 (PLEASE MWTINIATIC OR TYPE ALL INFORMATION) Date: d 22,/8 City or Town of: NORTH ANDOVER To the llnlspp—eftor ldf Wires: By this application the-undersigned gives notice of his er intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant 4 Telephone NO. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) 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: kj'ru zdyl,el Completion of the followingtable may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire,Outlets No.of Hot Tubs Generators K VA No.of Luminaires Swimming Pool Above [i In- lyo—,-0-n"mergency Lighting grnd. grnd. F1 Battery Units No. of Receptacle Outlets No.of Oil Burners FM ALARMS I No. of Zones of Detection and No. of Switches No.of Gas Burners No. Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump IAYMbff 1Tons KW Na.of Self-Contained ............... No. of Waste Disposers Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal 0 Other Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equival ut 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 l-lP 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 hffiC 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 in, nee including"completed operation"coverage or its substantial equivalent. The ''y undersigned certifies that such covXe-rais in force,and has exhibited proof of�arn to�fi" he p suing office. CHECK ONE: INSURANCE U BOND F] OTHER F] (Specify:) d I certify, under thepains an([ ofpejurp)thattieinf9jultailon oil th plcand completegienalliesLl NO FIRM NAME: . Ue c It C. Mw .. Licensee: tj J19. Signature LTC.NO.: (If applicable,enter ex in ttq h ense pumber line) /2 Bus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L c, 147,s.57-61,security work requiles Department of ll(iibfio 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)F] owner [] owner's agent. Owner/Agent Signature Telephone No. PPRMITFEE.- $ The Commonwealth of 1V.tassachusetts - Depariment of)ndgstdg1 Acc d&ts Office of Invesilgations 600 Washington Street Boston,.MA 02111 vww.rnass:gov1d1a Wgrkers' Compensation Insurance.Affidavit:Buffders/Cony.aci-ors)ElectxzclanslPlibnbers A oullicalnt Information Please Print LeaWy Name(Business/Organization/lndividual,): �' l .A.ddress: �► i G l City/State/Zip: Phone#:_ .Axe u an.employer?Check the appropriate box: Type of project(required): 1. x am a employer with L 4. ❑I am a general contractor and I 6. ❑New constcaction employees(fall and/or patt c)* have Riredthe sub-contractors 2. I am a sole proprietor or partner•• listed on the attached sheet.x 7• ❑Remodeling ship andlave no.employees These sub-contractors have 8. []Demolition. working forme in any capacity. workers°comp.insurance. 9, ❑:Building addition [No workers' comp.insurance 5, ❑We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised.theix 3.[l I am a homeowner doing all work right of exemption perMGL 11.0 Plumbingxepairs or elitions myself[No workers' comp. c.152,§1(4),andwehaveno 12,pRoofxepairs insurancere iced. oyees.[No workers' � ) empl 13.�Othex comp.insurance required.] NAny applicantthat checks box#I must also fill outthe section below showingtheirworkers'compensationpolicy information. f'Hcmeownerswho sabmitihis affidavit indicatingthey9s d9ing allworK and then hiro outsido contractors must submit anew affidavit indloatifig such. 1'Contractors that checkthis box must attached au additional sheetshowingthe name ofthe sub-contractors andtheir workers'comp,policy information. lam an emyloyer that isproviding lvorkers'compensation insurance for my ernpl'oyees BelotY is thepolicy tc�t�job site information. Insurance Company Name% Policy#or Self ins.Lic.ff: Expiration.Dato Sob Site Address, l City/State/Zip: v° r Attach a copy of the workers'compensa ' n-policy declaration page(showing the policy number and expiration.date). Failure to secure eoverago.as requimcT.under Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/or one.-year imprison ent,as well as civil,penalties is the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. -1do i areby eertify e A a a d penatties ofperjury that Fite information provideciabove is tru nd eorreet, sip-nature: J Date: Phone##: 3 Official use oltiy, vo not Write in this area,to be compieteri ny city or town official: City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health. 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Coatact Pura on: Phone#: ST-EPHEN M JURA 11-1 555 SA[L€M ST - NORTH ANDOVER MA t1#$�5 37og rR Fold,Then Detach Along All Perforations °• ,..�COMMONINEALTHOF •M�X,S�IECHUSE�'i'S.. :: . • • - • a E1C fi I C1 ANS ISSUES �H FOLLOWlT1G �iNSE AS ! f3EG 15ED MAST E ELECTf�1�1cc STEEHEN 1� JUBAI AR I 555 SALEM SY._ � z tt Tl A` vE MA o�845 3-1.1 95 :.. _ 4460 . .. . . , Date....,.... ......... s O�p► TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING * .. law • , s � �BACHUa�� This certifies that .: ..........'........ k t . . has permission to perform , ..�s. .......... .......1.. .................................... wiring in the building of...... .......................................... at ." w l ,North Andover,Mass. Fee.............................Lic.No. ......... ........5 . ................................................................... 3 ELECTRICAL INSPECTOR i - Check# `- Commonwealth of Massachusetts Official Use O y Permit No. Department ®f Fire Services BOARD OF FIRE PREVENTION REGULATIONS [Roccupancy v 1/n y and Fee Checked 71 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .All work to be performed in accordance with the Massachusetts Electrical Code(NEC),5 7 CMR .00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: -Z / _ City or Town of: NORTH ANDOVER To the Inspector df Wir s: By this application the undersigned gives notice of his or r intentio to perform the electrical work described below. Location(Street&Number) �/ l Owner or Tenant v Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) 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: r,.1,0 Completion of thefollowing table may be waived by the Inspector of 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 mergency Lighting rnd. grnd. Batter 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 Ranges No.of Air Cond. Tons Tot No.of Alerting Devices No.of Waste Disposers HeatPump Number Tons KW No.of Self-Contained r Totals: "' Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No. of Dryers Heating Appliances KW SecN.o Systems:* es or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices ox Equivalent ecommunications No.Hydromassage Bathtubs No.of Motors Total HP Tel No.of Devices or E u valent OTHER: �\ Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of ectri al Work: (When required by municipal policy.) (� Work to Start: L Inspections to be requested in accordance with WC Rule 10,and upon completion. INSURANCE CO RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov age is in force,and has exhibited proof of sa e to he permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 4 I certify,under thep J ains a d enalties o erj c ,that the l ormaflaA 03 this apple ation is true and comte ple . FIRM NAME: . 0 f P f,1( LTC.NO.: , Licensee: r plwtA "n-�1W Signature 11M LTC.NO.. (If applicable,enter xempt"in Ife licens number line.) Bus.Tel.No.: Address: <. 11 (, 4 6Ve� Alt.Tel.No.: *Per M.G.L c. 147,S. 7-61,security work requir s Depairtmelifof P blic Safety" "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 PERMIT FEE. $ Signature Telephone No. _ _ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the r notification of completion of the work as required in M.G.L.c.143,§3L. , Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass IN Failed (]' Re-Inspection Required($.)D. Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH ECTION: Pass Rr Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: s -� J FINAL INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Division of Professional Licensure: License Search Page I of I The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home)Division of Professional Licensure> ONLINE SERVICES Check a License Check A Pi-ofes Sion al License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:STEPHEN M. JUBA JR. REFERENCES& Business: JUBA ELECTRIC CO INC RELATED INFO N ANDOVER,MA Disclaimer Regarding Website License Searches Glossary of License Status Licensing Board: ELECTRICIANS Codes License Type: MASTER ELECTRICIAN More... TYPE CLASS:A License Number: 5933 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Friday,March 28,2014 at 8:17:24 AM. 0 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us//,,Liblicl-ubLicenseQ.asp?board code=EL&type class= A&li... 3/28/2014 Date . . . . .. r TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . . . . : / ~ . . . . . . . . . . . . . . . . . . . . . . I has permission to perform . . . :' .'. . . . wiring in the building of . . . . . . � . . . . . . . . . . . . . . . . . . . . at . . �Z ./ R ,North: ndover, Mass. Fee Lic. No. , 72 . ELECTRI AL INSPECTOR I Chck# �" �� f, a;l Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS �y" li (Please add zia codes & electrician's cell#� Occupancy and Fee Checked [Rev. (leave blank) contract &bld permit#if applicable.)— I` APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INTORMATION) Date: City or Town of: AJ O rhffi pnt By this application the undersigned gives notice of his or h�e�mt�� To the Inspector of Wires: ention to perform the electrical work described below. Location(Street&Number) Ci �� (�L Owner or Tenant e, Telephone No. Owner's Address — Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Volts Overhead Amps / _ ❑ Undgrd ❑ No. of Meters ` umtier of peedei s and Ai-pacity Location and Nature of Proposed Electrical Worlc: N ��CcT i01 `` J c-u ci , i earn Completion of tlne,follolving table may be ivaived by the Inspector of 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 mergency ig r jig rnd. rid. Batter 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 j Initiatin Devices No.of Ranges No, of Air Cond. Tons Tota1 No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertingy Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal ..._._Con_nection ❑ Other No.of Dryers Heating Appliances KW ecurity Systems: No, of Water No.of Devic r Equivalent � Heaters KW No. ofNo. of Signs Ballasts D a Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: OTHER: _ No.of Devices or Equivalent I .��/� i u Attach additional detail ifdesired, or as required by the Inspector of 111tres. Estimated Value f Electrical Work: 7F9. (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. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER X (Specify:) Self Insured Icettify, under the palms and penalties ofpetjury,that the infotanatio� ort this application is true and complete. FIRM NAME: ADT LLC DBA ADT Security 2 LIC.NO.: C-172 Licensee: Thomas J•Lee ignature ` � �e I a lncablP.enter "exempt"in the I' ense number line.) - `-" f LTC.NO.: C-172 �f PP - Address: �' C�L t��-� r �� ` Bus.Tel.No.:�n y `>��y t�7JQ� t \his, tv 1 t v JU Alt,Tel.No.:_'Security System Contractor License required for this work;if applicable,enter the license number here: 001779 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/Agent ❑owner's agent. Signature Telephone No• PERMIT FEE: $711 ':COMMONWEALTH OF"RE uliM k17AS: AC�fitS1"�a.�. ELECTRICIANS A.RE_GIS.T'ERED SYSTEM CONTRALTO . ISSUES.THE ABOVE LICENSE TO: ADl L1 C. UBA ALIT SECURITY ` 1 H0MAS. :J LEE.. � '"(N�VERSITY AVE din :PSTW0:0D MA 02090-231X 112 :C 07/31/13 2019.34 Fold Than Detach Along All Perforations 1 I ' i Date.... . ............ ............. NORTH 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSAC14US This certifies that ............ ........ .............................. has permission to perform .............. ................................. wiring in the building of.........N:'-Lo.............................I........................ ..........L 7 ........ . Ax.16,c z I/ r................c,.._. ,,North Andover,Mass. .. . Fee ........... A'-RIAL INSPECTOR Lic.No. ...............ia Check # 0806 Official.Use,Only PerraitNo.— Zrg� >6 r-u and Fee Checked Q BOARD OF FIRE PREVENTION REGULATINS [Occupancy Rev.1/07] 9 OCEIVabial-&-) APPLICATION FOR PERMIT TO PERFORM ELEGTRICAL WORE AU work to be p6r1hrinef J in necordance Nvifli the Massachusetts Electrical Code 7 CMR 1-1 00 (PLEASEPRflffBfBVK0Rn ."ITL OmmTrom Date: 7"I 1Z, City or Towfi of.. 74o- 7 1 To the 1nSP'kCt02-'0 wrires: By this application the undersigned gives notice of 1 or rinlentiqfl to perflaryntlia electrical work described below. Location (Street fir.Number) 11G4 i!j (1'c Owner or Tenant ""J set"'? 10 Z Telephone No- Owner's Address Is this permit in conjunction with a build poxmi Yes D" Na El (CherJEApIpropriate.Box) Purpose of Building UtilftyAuthorlzntion No. Existing Service Amps Volts OverbeadEl TJndgrd 0 No. of Meters New Service Amps 1 Volts OverhendEl Unrlgrd E] No.of Meters Number of Feeders and Ampneity. (—;a-M 1 14 rw� Location and Nature of Proposed Electricni Work! L,rc7�ep, e,e- IkL Canipleflon qfthaficillai fly table map he ivahted b))the.firs error al-J-1, o.Or Total of-Recessed Luminaires No.orCeil,-Susp.(Paddle)Finns N Trnnsformers XCVA No. of-Luminnire Outlets No.of Not Tubs Ganerntors ICVA Na.of Luminaires Swimming Pool Above M In- F, No.ol-limarganney erg ing Rrnd. gra d. Britter 7j y nits No.ofRaceptnele Outlets No.of Oil Burners FiRri,ALAims INo. 07zone; No.of Switches No.of Gns Burners No.of- etertion:and Initiating Devices No. of Ranges No.of AJr Cond. Total No.ofAlertingbevlces Tons klentrump Number I It Nmors-e i—f-contained No. of Waste Disposers TotaN.- Bet No.of'Dishwnshers SpacdA-rea Renting IaY Local❑ [12un'C'Pal El other Connection Securi No.of Dryers Heating Applinrices IM 199, No.Of Water No. or Na, of No.ty of a or'Et quivnient Heaters lav Ballasts Data Wiring: I Signis No.of Devices or Equivrilunt No.Hydromassrige Bathtubs No.ormators Total HP Talecommnnications; W"Jing. No.of'Devicas or)Rquivale"t OTHER: /I Hach addillot int detail Jj'dulred,ar as required by r/j e 1tyxpe ctor of Wj 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- IN*S U RAN CE:C 0 VEMRkGE.--Un I rs s'-w a ive d-by-*I h u:own cr�rf c�-Vdhh i t-* ff :6 6—plra brit the licensee provides proof of flablllty Insurance including'completed operation"coverage or its substandal,equivalent- Thi undersigned certifies thatsuch coverage is!afore%and has exhibited proof ofs ejoift. ermlit is�uiryff office_ CHECK ONE: INSUR-X��E. BOND F1 OTBEFL ec CSP It yi-t' 044=4 arald 1011-0ir. -a F NO� 'T r.1RM N A RE, rd M Licensee: L), b Signature Lic.No Wapp I re a b IL t T1 in[h dense nupiber Bus.Tel,No-. Addres /V Alt.TO.No. OPerlVL(3J,,c. 147,s.57-61,security wo&requires Deparimerrt nfPublia Safety"S"License: Lie.No. ONVNERIS INSURANCE WAIVER: I am aware that the Licensee does noi have the liability insurance coverage rage required by law. By my signature below,I hereby waive this requirement. [am the(check one)El mmer Q_Mna!E2T,2 Owner/Agent Signature Telephone No. PERWT FEE: S Vie Connizompealth.o,f ijaysaciliusettr _ Department of Indusirial_Accadepzfs 1 CO-119 esS Sheet, Srazt�;z00 Bostopa,M4 0.2.E p4&7 IOim iv.Ynass go-pld� Workers' Compensation Insurance A-Midnxit: D-ender•s/Contraetoa stu-llectricians/M rs Pieais�IPa�h�g,;� 'dill. Dame [Business/argaaizationllndividual}: Address: City/stee,f ip. Phone#: �re you:�� employer?Cheelc the appropriate bwc .Q I am a eaxtployer with. 4 ❑ I Mn a general contractor and I Type of prof eet(rrequRred): * .have hired the sub-contractors d• Q New construction employees {full andlor part time}. listed on the attached sheet_ 7. []Remodeling Q'I am a sole proprietor orpartner Those sub-contraatoas have ship.and have no employees 8. M bemoWon worldng forme in any capacity. employees and have workers' comp.insurance' comp,ins rance_t 9_ ❑Building addition [No workers h ffi o required-] officers have exercised their 5_ [] We area corporation and its 10_El EIectrical repairs or additions .❑ m I a a 7iameowner doing all work 1 I.❑Plumbing repairs or additions , myself [No workers' camp_ right of exemption per MGL 12 ❑Roof repairs ins-araaace required]t c. 151 §1(4).and we nave no employees.LbTo workers' 13.n Other comp,insurance requEm L] .ny nppli=t6at checks box Kl mustaIso iiII out:the section below showing their-vvorlcers,compensation policy information_ ra neowners who snbmitthis affidavit indicating they are doing all work and.-then hire our_sida contractors must submit a aew affidavit indicating such- ontructurs that additional.sbeetsbowingthe name o£the sub-contractors and sintewbetherarnotthose entities have iployecs. ifthe sub-caatmctors have employees,they must provide their workers'comp,policy number. niz all eirpMyeB•ifiat is providaigivollrers'007'Pelisafi0l: histirance foy-my' 9,111P10yeeS. BefD)P IS tle2_ID&Y al9dy'Ob Ate jF077P7afT07� . surance.CoanpanyName: Aicy#or Self-i:ds.Lic.#: FxpiratianDate: )b site Address: City/statuaip: attach a copy of the worheirs' compensation pokey deeiaratiola page(shuwing the policy number sud expiration date). afltare to secure coverage as required Lander Section 25A ofMGL c. 152 can lead to the ianposition ofcr bihal penalties of a ne tap to $1;500_00 and/or one year ianprisoaaanent,as well as civil penalties in the form'of a STOP WORD DRDER and a fine Cup to$250.00 a day againstthe violator. Be advised that,copy of this staterflentm,aybe forwardedto the Offi-ce of ivestigations of the DIA.forinsnrance coverage verification._ da fiereby e! r, v uYider the albs and ena&a9 DfPe1Y11rY drat t11e hifonllaiioti,proAled above is true and correct Era a hone#- Of-flota>'use only. Do no-9 iurite in tiis area,to be coPnP7eted by cit}r Dr io►Nra official Cit3r_oaryTovm: f. penmgt(Liceuse# lssadmg, 6th0arity(ev'rele one): 1.-Bo4yi `b Ji$ealth 2.JBadingDepartfhent 3. City/'I vm Clerk 4.Mleetu,cal Inspector 5.Plumbing li spector 6. Otlaetr Contact Persian: Date......T.................�...�..,� NORTI{ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 1SSACHUSEt ; This certifies that ................................ .....�.�.- ..../�................................... has permission to perform ....... ..IUZA.. ............ ......................................... wiring in the building of................ L.'�?....................................................... at.../. ...... � ,®. ��! ........b &.............. .North Andover,Mass. c Fee. .:�........... Lic.No. ............... ..... � �_ ' ELECCRICAL INSP�CTOR ,✓9. Check # 7 1 ®76 Corrunowmealdt,o/I/la3eacliaealfd Official Use Only Permit No. c/ 0 734 .. 2,,.arfmorrf of-7ira S mi w Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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), 27 CMR 2.00 (PLEASE PRINT IN INK OR TPP I,INF' RAIA ION) Date: f Z City or Town of: �, , t/e r To the.Inspector of Wit s: By this application the undersigned gives notice of his o he/r ititentio to perform li electrical work described below. Location(Street&Number) ! /Z cl 72 Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 2 I�� 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: -,70 64��IT A )/9 I Cora letion of the 1ollowin table may be ipaived b,the Ins ector ol'Fhires. No.of Recessed Luminaires No.of CeiI:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In o.o mergency Lighting No.of Luminaires Swimming Pool 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 etection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons g No.of Waste Disposers Heat Pump Number Tons If o.of Self-Contained Totals: �...."''..__.M...."�"" 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 1�n 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 derail 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'nsurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of s e to the pe it issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ?/ j�2 X j; I cert ,under the aims rr rd penit'es oif erjury,tl(rt the in rmatiorr au t ris applrcatl r is true and our et (.-� FIRM NAME: v c"fE�c /� 1 _�-. LIC.NO.: �/ Licensee: 'h �✓CJ�� Signature _ (" L1C.NO.: (Ifapplicabte, ea! "eYeJJt t"ilt line IiCeJ7SeT1UgJberlT $ p Bus.Tel.No.! Address: v5 t c A AU(3 t Alt.Tel.No. --I' *Per M.G.L.c. 147,s.57-61,security wqg requires Departni6nt ofPublic 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 a eat. Owner/Agent Signature Telephone No. PERMIT FEE: $