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Home My WebLink AboutWiring permit - Permits #12885-1 - 42 KINGSTON STREET 11/20/2015 I _ 9 Date.J/ � � .. .............. o3 •' om TOWN OF NORTH ANDOVER * �. » PERMIT FOR WIRING HU55� This certifies that ... ................................................... has permission to perform .....Nr � .� . ......::... .......................................... wiring in the building of r d M ................. ............................................. at ... ..... ..f. � �.. �� r� � .......,North Andover,Mass. Fee............. .......Lic.No.2��.� � ......................... ................................... � � ELECTRICAL INSPECTOR Check# _ Commonwealth of Massachusetts ettd vas Only Department Of Fite Services Permit No. �... BOARD OF FIRE PREVENTION REGULATIONS APPLICATION IT TO PERFORM ELECTRtCAL WORK All work to be perforated in accordance with the Massachusetts Mectzical Cod (MEQ 527 CMR.12.00 (PLWE PRINT IN INK OR ME AU.INFORM.ATIOA9 Date: ,22 __- City or Town Of: � �,c;� r� ... To the Impector of?Fires: c eat , a U enteention to perform Ike electrical work described below. ,By thhisis application the r figi ves volt of has or h r i Lo Owner or Tenet !1'r > ��. , ,. Telephone No. Owner's Address b this permit in conjunction with a building permit? Yes 0 ' No Building Permit# purpose of Building Utility Authorization No. Existing Service ✓O Amps 6k / 0V'olts Overhead 0 Undgrd No.of Meters New Service Amps / Volts Overhead Undgrd No.of Meters Number of p' ers and pacity Location and Mature of proposed Electrical Work: , } ,:�� ..�% m4KI IA, ✓ ��. ' Com letion o able inav be waived b the Ins ector o Wires. oa No.of Recessed Fixtures No.of Ceii.«S .(Paddle)Fans T��nsformer s �A No.of Lighting Outlets No.of Hot Tubs Generators ova nmmergency g No.o#'M ting Sw3 gag pow rttd. 0 t8,a t}sadts No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones o,o etec on an No.of fiches No.of Gas Burners gntlatin Devices No.of Ranges No.of Air Coxed. Tons FDoeleoc Alerting Devices No.of Waste Disposers Tails nm�ew ens ��.� W outs ne „" ""' "" nlAlert IDevl ces N`o.of Dishwashers Space/Area Heating Conree pbian other No.of Dryers Heating Appliances Security ysterns: No.of IDevices or E uiXdMt ea.01 water o.o ®.® Data Wfrictg$ Beaters Si ns Ballasts ly'a.of TDevi or E ulvalent er ecomrnurt ca Otte r ngr No.Idydrorctassage Bathtubs No.of Motors 'Total No.of 1Devices ar E uivalent OTHER: g CE CO G : Unless waived by the owner,no perrait for the perfornmee of clear, work may issue unless the licensee provides proof of liability Insurance including"completed operation"coverage or its substantifil.0quiV810M The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuingoffice. CHECK ONE: INSURANCE BOND 0 OTC M 0 (Specify: (�xpiraticn 17ate) Estimated Value of Electrical Work ' CIS) (When required bymunicipal policy.) Work to :1y 1? /,� ections to be requested in accordance with MEC Rule 10,and upon completion, l certify, der the p sand pert cs of perjury,that the Information on this app ' ' n is true comp Current Insurancecerrdfa rttust6r on Jli'c to star office r �+xrll out vrJt welt 11�ldcaitora FERM NAME: D.L; " ' /��/t c, -, �r;/mot ' rr -;s ��c. LIC'.NO.: Licensee: fz:_ Signature .` LIC.NO.: -- a licable,enter " pt•�in$ e license n bar 1i e,) Bus.Tel.No.tZ% (I� PP Addr : rr / /' J1 ^ S Alt."Tel.No. OWNER' S S F 7 : Tarn aware that the Licensee does not have the liability insurance coverage normally required by law. Ey rrxy s` ture below,z hereby waive this xegqu' t I am the(check.one owner owner's a ent. iwnat�i�gent Telephone No. PERMIT ° '� g The Commonwealth of Massachusetts Department of Industrial Accidents via Office of Investigations ug, 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le>ribly Name(Business/Organization/Individual): r(�j} Address: ` ,%�/�;1,�� 2 d �J City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with c�--� 4. I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.) 5. [] We are a corporation and its 10.❑ Electrical repairs or additions re 3.❑ I qu a homeowner doing all work officers have exercised their I LEl Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.Q Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 1311 Other 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 affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: G(� �V�� i'��/ Expiration Date: �S Job Site Address: >>� s'``' City/State/Zip: / (!'" f /U P Div rS Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pai s and enaltie ofperjury that the information provided(above is true and correct i ature: Date: Phone#: Offccial use only. Do not write in this area,to be completed by city or town offwiaz 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: Phone#: