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Home My WebLink AboutWiring Permit - Permits #12495-1 - 132 KINGSTON STREET 7/20/2015 Date.... ............................. OF NORT/y ova ooM TOWN OF NORTH ANDOVER p PERMIT FOR WIRING t°°�'?;:�;;�',' • ICI �8AcHut) This certifies that ....... f".. �'�?` ::�.........,. :..r �...5... � m� .., ................. has permission to perform r.G . .... .......' �- .. p '. . .F::.�� ......: e �'?..f .................................. wiring in the building of......... ' .�.. f � c'E;✓. ��....................I......................... at ? ° � ' ............................f North Andover Mass. p. ,..... r; A� Fee..............................Lic.N�' ELECTRICAL INSPECTOR Check# Commonwealth ®f Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.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 PRTNT INMK OR TYPE ALL INFORMATION) Date:"]Ls it- J0, Q10i S City or Town of: NORTH ANDOVER To the Inspec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) i t its--v J0,L, 4-t -, Owner or Tenant tt,/c l I l k Telephone No. Owner's Address 5e,t-cG 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: ' Completion of the following 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- Elo.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 Burgers No.of Detection and Initiating Devices — No.of Ranges 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: I 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 Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices ox Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or E u valent 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 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 V BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofpetjuty,that the information on this application is true and complete. FIRM NAME: v , r� /Jv s' ��s _ LIC.NO.: Licensee:L_ ✓`e,5�,o l t A-i f�2 Signatur 't LTC.NO.: (If applicable, enter 'ex$mpt"in the license numb% line.) Bus.Tel.No. �� tag /04, 7 Address: Its ' e c,4 /U0 t�d'o ✓ i°L''z�' Alt.Tel.No. rc/� & *Per M.G.L c. 147,s.57-6 ,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑owner's agent. Owner/Agent PERMIT FEE.$,j,— Signature Telephone No. The Commonwealth of Massachusetts _ Department of IndustrialAecideftts 1 Congress Street,Suite 100 .Boston,MA 02114 2017 �r www.mass.gov/dia o�M stil v` -Workers'Compensation Insurance Affidavit:Builders/Contractors/Tlectricians/Plumber s. TO BE FILED WITH THE PERMITTING AU•I'H01IITY. Please 12rint Le 'bl A ''licantlDformation Name,(Business/Orgariization/Zndividual): 4,AZI_ C Address: L^ Wa e`"j c� v-)o ✓ Phone#: 7�l City/State/Zip: p pp p Type of project(rrequired): Are you employer?er. Check the a ro riate box: em to ees full and/or part time).` 7. [1 Ner�v'constructIon 1. I am a employer with / P y torking for mein 8. F1 Remo del 2•Q I an a sole proprietor or partnership and have no employees ing any capacity.[No workers'comp.insurance required.] 9 Demolition 3.[]I am a homeowner doing all workmysel£[No workers'comp.insurance required]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.[�Electrical repairs or additiots ensure that all contractors either have workers'compensation insurance or are sole repairs Or additions proprietors with no employees. Ia.C1 Pr'm. g 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11 Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.Q We area corporatiori and its,officers have exercised their right of exemption per MOL c. ave no employees.[No workers'comp.insurance required.] 152,§1(4),and�Ne h xAny applicant that checks bok#.t must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•. 1 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(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ers'compensation insurance for my employees. Pelow is the policy andjoh site X am an employer'that is providingworlc information. Insurance Company Name: Expiration Date: Policy#or Self ins.Lic.#: 44-51 / <,,�• � s � City/State/Zip: Job Site Address: Attach a copy of the woxkers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL e.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,A cop of this statement:ml as civil ay be forwarded to theff"i e ies in the form of a STOP WORK fuvOesgdtions of tER and a he DIA for insurancee of up to 00 a day against the violator.A copy coverage verification. I do hereby and the ins ripen tit' ofperyury that the information provided above ove is true and correct Date: cv 4 Si atur Phone#: 7 97_ y 9 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 Phone#: Contact Person: