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Home My WebLink AboutWiring permit - Permits #12649-1 - 50 KINGSTON STREET 9/8/2015 Date �.... . ................. s �'OW`v A' OF NORTH A14DOVER F3 �FORTH qry PERMIT FOR WIRING °+ono' •T M,83ACH%U5� .,d C a t F�.. ifies that ..........� .. ....... .I................ This cert ...... fission to perform ...... ......... has perml ,. ...I......,.. wiring in the building North Allover,Mass. at CpI INSPECTOR -�' 1.1C No2jr�,� ............ ELECTRI Fee..... ............ Check# .� (f1mmonwea&o f Mamac4wetb Official Use Only 2epartment of cc��ire Service c� Permit No. 1 t-1 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 PC),527 CMR 12.00 _ (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: �� 1�Nn6tje l To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work desc ibed below. t Location(Street&Number) Owner or T t Telephone o. G' ' Owner's Address J f C' Yt T— NR t D �1/0a: /y Is this permit in conjunction with a b Iding 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: (,( /> i ✓-1yq Re 4, Completion ofthefollowing table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: P (Paddle)Paddle)Fans Total TransTsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ElIn- ❑ o.o Units cy ig mg rnd. rnd. 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 Ran es No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat pumpNumber Tons KW No.of Self-Contained P Total .......... ................ Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Cyonnection No,of Dryers Heating Appliances KW SecNo of Devices or Equivalent No.of Water ' No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: 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: 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 �nq BOND ❑ OTHER ❑ (Specify:) I certify,under the p 'ns and Iles of perjury,that the information on this application is true and complete. FIRM NAME: Y jG' L t'M LIC.NO.:� Licensee: Signature _ LIC.NO.: (Ifopplicable,enter "exempt"in the license member line. Bus.Tel.No.: _Z"i, Address: 1-i�✓ 1 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 PERMIT FEE: $ Signature Telephone No. the Commonwearth ofAjassgdzusetts z. Dep trt�nent of Indust—Hal Accidents N Z Congress Street,Suite 100 p d -Boston,AAA.02114 2017 gat www.m ass.go Mat ;• uilder(s/Contractors/Ele Sy. oxexs'CoznpensatxoxtZnsuxaxice Affidavit:Bctrzcianslenmbexs. TO B�AILED W.fTH TBE PERME'7:TII��•AT1T3�ORI'Z'�''. A licant7nformation PleasePxint iLegibly Name, (BLisiuess/OrganizationlSndividual)- ! VA!� .A.ddxess: UJ URA/ `�,l `� may► ' 7 e 77/ fV1 city/state/zip: �(�7" ��/�/ •�'/� Phone#: � • Are an employer?Checkt&appropriate box: Type of project()Vequixed): 1.0 la m.a employer v,�ith : employees(Roll and/or part-time).* 7. ❑New. construction 2, am a sole proprietor or partnership and have no employees working for me in &. Remodelhig any capacity.[Noworkers'comp.insurance required.] c) ❑Demolition 3..Q lam a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition 4.Q1 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 em�loyees. 12.Q Plumbing repairs or additions 5.Q I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insruance.� 14.❑Other 6.❑We are a corporation and its officers have exerclsedtheir right of exemption perMel,V. 152,§1(4),and we have ncl employees.[No workers'comp.insurance required.] 'Any applicant that checks box#i must also fill out the section below showing theirworkers'compensation policy information. 'i Homeowners who submit khis Adavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. ?Contractors that check this box must-Otached 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 Mat ispi'ovidingwork`ers'compensation insurancefor my employees'Below is thepoZicy andjob site information. Tnsuxauce Company Name,- :Policy#or Self-ins,Lic.4' ExpirationDate: Job Site Address: /� ~ � y _ r�U � K' - � ely JT' City/Statemp: Attach a copy of the workers'coxnpensation•policy declaration.page(showing the policy number and expiration(late). 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. 1 do hereby ee t under the Ws andpenalties ofperiury t]aat the information provided alcove is fate and correct. Si nature: Date: Phone# < L Official use only. ))o not write in this area,to be completed by city or town official. City or Town: Permit/License 4 Issuing Authority(circle one): 1.Board of Health, 2.Building Department 3.City/'Town Clerk 4.Electrical Yuspector 5.PlumbingI Spector 6.Other Contact Person: Phone If: ..COIViIViONU1/E4LTH OF iVIASSACHUSETTS ® ® ® o0 ® e _:-'BOA �F EL.ECTRICiANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ELECT )C I AN` � ROGEt Y BERGERON a y 38 AUBURN r i W J HA.VERHILL MA O1$30 5004 26'317 E: .... ..:07731 a 6. .. .: :89912