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Home My WebLink AboutWiring Permit - Permits #12650-1 - 78 KINGSTON STREET 9/8/2015 Date.`�.. . .. i �.............. I TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING 88ACHUg� { l ,...... . ....." '. y- . .g� This certifies that . has permission to perform .................. A..........�...�` ....................... wiringin the building of......�n�....................................................................................... North Andover,Ma ss. Fee... t�: Lic.No. .. .�. ............. ..... ----, ELECIR...CALINSPECTOR Check# E (fommonwea&of Mamachusetb Official Use Only 2epartment of ire Service.4 Permit No. BOARD OF FIRE PREVENTION REGULATIONS [Rev.1p07)y and Fee Checked (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: f City or Town of. L, /w1'/°ll/mot/ 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) Owner or Tenant Telephone No. r79 0— 7,� 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: jN Completion ofthefolloWng 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 -VA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency 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 Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number"""Tons KW No.of Self-Contained Totals: """" """"".""""""' 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 Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with WC 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 o erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee:_ ' - V �Y Signature LIC.NO.:� � (Ifapplicable, s ter "exempt�"�in the license numbine.) / Bus.Tel.No.: Address: , / ''jU/�.lV � �e'� 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 Signature Telephone No. PERMIT FEE: $ the Commonwealth ofMassos huseits Department of IndlusfidalAceldents P I Congress Street,Suite 100 Boston,MA 02 (�.( .�14-2ry017 Wovkers'Compensation Insurauce_Affidavit:�3u�ders/ContractoxslElectriciansl�X�azabers• 'Z'O BE,MET)�TJ�TUE�'ERI4�CT7:�T�•AUTHORITY. Applicant xnformatiou. P/ Please Print Loaitbly Namo(Business/organization divi(jual): Address: J �/ #U0(jd2AI y� l'( W�l�� A k Phone Cx�ylState/Zip: . , Areyou an employer?Checkfh.e RUrr'priate box: Type of project()Vequired): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New. construction 2, ar a sole proprietor or partnership and have no employees working fox me in 8. R.emo delilig any capacity.[Noworkers'comp.insurance required] 9, ❑Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner audwill be hiring contractors to conduct all work on my property. I will ensure that allcontractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions, proprietors with no employees. 12.0 Plumbing repairs or additions 5.E]I am a general contractor and l have hiredthe sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insruaace,* 14.❑Other 6.Q We are a corporation and its of�cers have exercised their right of exemption per MGL G. 152,§1(4),and we have nc,employees.[No workers'comp,insurance required.] ,; *Any applicant that checks box must also fill out;the sectionbelowshowingtheirworkers'compensation policyinform,ation. Y Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must siibmit a new affidavit indicating such. rContractors that checltthis box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Fthe sub-contractors liave employees,they must provide their workers'comp.policy number. am are employer that ispi'ol�iding wor7cers'compensation insurance for my employees'below is thepolicy andjob site information. Thsurance Company Name.- Policy#or Self ins,Lic.##: Expiration Date: Job Site Address: A — " 3 02 r( 1��M� ly 151r City/State/Zip: 4144/11 ayelk ' A,.ttach a copy of the•worker's'compensation-policy declaration.page(shoving the policy number and.expiration clate). 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 imprisomnent,as yell 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 Snvestigatlons of the DIA.for insurance coverage verification. X do hereby ee under the ns andpenaldes ofpeljz�ry that the informationpr'ovicleci above is true n�reef Date: Signature: Phone# Official use onty. .Do not1prite in this area,to be completed by city or town official. City or Town: PermitlLicense# Issuing Authority(circle one)- i 1.Hoard offfealth 1 JBuildinglDepartm.ent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persona: phone#: i :COMMONWE4LTW OF MR:SSACHUSETI'S ® ® ® e ® BOARn t�F ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ELECTRICIAN', ROGEk Y B E R G E R 0 N""' On. 38 AUBU I" i J F�A.VERH1 L..:". :MA 01830 5004 26`317 ... I ... ' 89912