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Home My WebLink AboutWiring permit - Permits #12886-1 - 38 KINGSTON STREET 11/20/2015 Date.......e� ` . .......... �NORrH� TOWN OF NORTH ANDOVER '- PERMIT FOR WIRING socHUs� This certifies that ......... �e � has permission to perform ' . .... ..�:..... N° ..............................I..................... wiring in the building of...................... . .F �......................................................... at ,4.: North Andover Mass. I ......... ................. .`-..:.....................................f Fee . Lic.No. ....... .................................................................................... ELECTRICAL INSPECTOR k Check# Commonwealth of Massachusetts osne,d V00 Onlypad ant of Firs Services err it No. � BOARD OF FIRE PREVENTION REGULATIONS APPLICATIONIT TO PERFORM ELECTRXAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR.12.00 (PLWEPR VTININKOR ME AU,JNFORM.A7?OA9 ate: --- City or Town of: To the Inspector of fires: By this application the undmi gives��tice of his or her intention to performs the electrical work described below. Location(Street Nu er) . ` ti f Owner or Tenant ' Telephone No. Owner's Address `? Is this permit in conjunction with a building permit? Yes 0No Building Permit Purpose of Bullwng Utility Authorization No. Existing Service 90 Amps /'-.) / c`O Molts Overhead Undgrd No.of Meters New_jgrviceAmps / Volts Overhead 0 Undgrd 0 No.of Meters Number of Feeders and Ampacity .� Location and Nature of proposed Electrical work. : ,.� sac- .�� .% - Completion o the ollowin table be vaBv the Ins actor a Wires. 0.o a No.of Recessed es No.of CelieS .(Paddle)parrs Transformers A No.of Lighting OutlXVA ets No.of Hot Tubs Generators l�'o.of S�v3 a�3'ool rrrd.e nddm flnig ncy g No.of R table Outlets No.of Oil Burners ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etas . Iraitiatin DD anevices No.of Ranges No.of Air Cond. Tans Pdo.of Alerting Devices No.of Waste Disposers Ta .....-.�.M.er.,. ons 0.0 e a ontaine ". """" Detection/Alert' Devices No.of Dishwashers Space/Area beating Local U Conn CIO ®firer No.of Dryers Heating Appliances stems: ecur ty y No.of Devices or E uivalent o.a star I 0.0 Ballasts bate`6Yiring: Heaters Si s No.of evices or E uivalent No.ldydromassage Bathtubs No.of Motors Total a eC° un aas No.of Devices or E uivalent OTHER: INSURANCE COVE Olu: 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 equivalea The p. undersigned certifies that such coverage is in force,and has exhibited proof of as=to the permit issuing office. CHECK ONE: INSURANCE BOND OTHER 0 (Specify: Wpixation Date) Estimated Value of Etc frical Work: I i:` ) �� (When required by municipal policy.) Work to bVections to be requested in accordance with NBC Mule 10,and upon completion. I ce der the p s card pen s of pedjury,that the Information on tlrls appdfcadon is trace cam Current .rusursance ceWfleate Inustbe Onflk 1ft our q�'lce d0ffldFV&"AMa&V hefliledout wdli each appllcave.% NAME- D,C-� i �/!/�c%Oe" L.ieensee: Signature LIC.NO.: ({�applicable,enter"" mpt"an tl a Ifcense n ber li e.) Bus.Tel.No.- 'Y,7 117 7'/n°/ Address: " �' �J1 S Alt.Tel.No.° OWMIAS S E W R: I am aware that the Licensee sloes not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I arc►the(check one Ej owner owner's a ent. Owner/Agent PERMIT FEE:Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lggibly Name(Business/Organization/Individual): Address: �� /�f�;tr � a-/d JI City/State/Zip: ��r_/�^�� MIq /ai z/ Phone#: `?V A.re you an employer?Check the appropriate box: Type of project(required): l. I am a employer with c -• 4. � I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 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. C] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box M 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. tContractors 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. A-, Insurance Company Name: Policy#or Self-ins.Lic.#: Gt/r��V�� J�'��/ Expiration Date: Job Site Address: City/State/Zip: 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 pailus and enaltie ofperjury that the information provided above is true and correct. Signature: Date: i ;i=� Phone#: Offaeial use only. Do not write in this area,to be completed by city or town offtciaL 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#: