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Home My WebLink AboutWiring Permit - Permits #12608-01 - 44 KINGSTON STREET 8/19/2015 Date ... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU This certifies that &.......... ..................................................... has permission to perform .......... wiring in the building of............ L ................................................................... at e- -, I............. . a 7�— ................... ...................Nor%Andover, Mass... Fee ........................Lic,No. .... ........... Z" ' ........ ELECTRICAL INSPECTOR Check# COmnWnu/ea&of Mad�a,54v_lef Official Use Only -� (� 2e,'arl`med'pre JerviceA Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank)' APPUCATGON FOR PERNT TO PERFORM Eli EC f(MCAL LNORK All work to be performed in accordance with the Massachusetts Electrical Code 4EC),5+27 CZAR 12,00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I c( I 15 City or `"own of: rj+� Avvdn Pt' 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) �`-A � r Owner or Tenant Telephone No, (Af r RI_�� Owner's Address � Is this permit in conjunction with a building permit? Yes ❑ NO (Check Appropriate Box) Purpose of Building Ne c'- '( r k Utility Authorization No. _ Existing Service_LM Amps Volts Overhead ❑ Undgrd No.of Meters t New Service Amps / Volts Overhead ❑ Undgrd No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Cl� L � ��218 Ica d J Completion of the follomin table may be waived by the Inspector of Wires, No, of Recessed Luminaires No, of'Ceit.-Susp. (Paddle)Fans TransTotal Trsformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires Swimming Pool Above ❑ In ❑ o. o mergency 1g mg . grnd, rnd. Battery Units No, of Receptacle Outlets No, of Oil Burners FIRE ALARMS No. of Zones No, of Switches Na of Gas Burners No. of Detection and Initiating Devices No.of Ranges No of Air Cond. Total No, of Alerting Devices Tons . No. of Waste Disposers Heat Pump 1\',umber Tons KW No, of Self-Contained Totals: ........ Detection/Alerting Devices No, of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Cyonnection No. of Dryers Heating Appliances KW SeCNo.Urit of Devi c7 s 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 Telecom No. f Devicesons or E uivWirinalent OTHER; C;u 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 0 GE: 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 ow ge is in force, and lips exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCEBOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties o perjuty, that the information,on this application is true and complete, FIRM NAME: 010 16n a k I A r LIC. NO,: Licensee: _Rn`Cnd�.-,Q �°,At-e (S(g rature �' �L1C, NO,; (Ifopplicable ente empt"in the cen e number line.) Bus, Tel,No,;G d Address: wo F � Alt.Tel. No.; *Per M.G.L. c. I47, 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 mj signature below, I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's a ent. Owner/Agent FE7RM-IT FED' '� Signature Telephone No. The Commonwealth of Massachusetts Department oflndustrialAccidents n X Congress Street;Suite 100 '< Boston,MA 02114-2017 f .�' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elmtricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information (( 1�` `Please Print L e ibl Name (Business/Organization/Individual): (- l ° L�� 1 ec e m Address: I AM R w ooJ �A Q /"1��-�V�-�'� ��i�, 0 1 CS C I -f City/State/Zip: .% Ahorie#: 71� 3 ca 1 Are y an employer?Check the appropriat box: Type of project(pequired): 1.11J`aam a employer with�,,4 _employees(full and/or part-time).* 7. n New construction 2,❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity,[No workers'comp.insurance required.] In I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 9. ❑Demolition 10 n Building addition 4.❑I 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.�ctrical repairs or additions proprietors with no employees. • 12,0 Plrunbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached ached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp•insnuance, 6.Q We area corporation and its officers have exercised their right of exemption per MGL c. 14,Q Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, t Homeowners who submit this af�idavit indicating they are doing all work and then hire outside contractors must stibmit anew affidavit indicating such. tContractors that check this box nrust•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 ivorkers'compensation insurance for'my employees.' .B'elow is the policy and job site information. (,tr�l(��vt f( v,i S4 �R1�>+ S n � eko0q r `C y Insurance Company Name: ' t 1 �G i n�' ' Policy#or Self ins,Lic.#:LU L— 0 0 0 14(o 1 "0 Expiration Date:j31 a a f I(, Job Site Address: � "l t< k ofi � _�J i @ ALAt AA _o)Ed(§ity/State/Zip: c,4� , « z (� 45 Attach a copy of the workers' 6016pensation policy declaration page(showing the policy number and expirati n date). Failure to secure coverage as required under MGL o. 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 instu•ance coverage verification. I do hereby certify rider tdie adns and penalties ofperjury that the information provided above is true and correct. K Sianattue: �j rA ° 1 c ,{ ALL- Date: Phone#: 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: i Phone#: } G � r soosfi�"E+nea ctoz cd;z!�6��-Cq-ay�,� ,.•� r diC �Y �� t i � t 4