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Home My WebLink AboutWiring Permit - Permits #12677-1 - 176 KARA DRIVE 9/15/2015 Date.... f of NORT/y 4 �'•�°o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,moo,,�;��•,�,-°��► s�CHU5� g - _ This certifies that i has permission to perform ........�3 --�4 V, , ............ ................ wiring in the buildi g of r at .......� .............. North Andover, Mass. Fee.....�.. ...... ...Lic. No.3 .. .. ........................... Check ELECMCALINSPECTOR i ' � up 12-1 <1 Official Use Only 44- Commonwealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 11071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CNM 12.00 (PLEASE-PRTNTINMK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVE'R 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) L74. 1912 W 4 Owner or Tenant 1—;Adf Telephone No. Owner's Address Is this permit in'conjuaction with a building permit? Yey'rQ No [I (Check Appropriate Box) Purpose of Building iv 01 C� Utility Authorization No. Existing Service_ Amps volts Overhead ❑ Undgrd F1 No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity ZJ Location qin.d Nature of Proposed I ctrical Work: ii Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above Ei In- E] No.of E mergency Lig ting grnd, grnd. BatteryUnits No.of Receptacle Outlets No.of Oil Burners ITHM ALARMS iNo. of Zones of Detection and No.of Switelies No.of Gas Burners No. Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Tons I KWSelf-Contained No. of Waste Disposers Totals: ................I................. Na.No.of Tot Detection/Alerting Devices.... No.of Dishwashers Space/Area Heating KW Local El Municipal El Other Connection Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent .......... ... .......... No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts . No.of Devices orEquiva ent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP Na.of Devices or Ea ulvalent OTHER: Attach additional detail if desired, or as required by the Inspector of J"res. 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 pen-nit 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 [I BOND [I OTHER El (Specify:) I certify, under thepains and penalties lfpe ' ir,that the Information on this application is true and complete. FIRM NAME:-.WOZil4lCk, LIC.NO.: Licensee: Signature LIC,NO.:33(�2 vle, ll i th lice number line.) (If applicable, enter "ex in Bus.Tel.No.: '79V—,23L::: � Address: /40/9 k,119 41, 1AP15? 01� Alt.Tel.No.: "79)1-22-J— V,27 *Per M.G.L c. 147,s.57-61,securityAork requires l6epartment 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)[I owner El owner's agent. Owner/Agent Signature Telephone No. PPRMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shalt be responsible for the _ notification of completion of the work as required in M.G.L,c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Sig ure. Date: ROUGH IN ECTION: Pass M V Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: 9�-1 7-1- FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of lfcdus&1aZAcczdeHts Conga ess Sheet,Suite 100 =:= F Boston,mA-02114 20T7 �< www.rnass.gov/dia o�M stile WoVke&,CompensationlnsurauceAffxdavit:Builders/Contractors(Electricians/klumbers, TO BE FILED WITH THE PER11ATT]NG.A11Tj10R4 Y. -Please,Print Legibly A llcant Information Name(Business/Oiganization/Individual): Address: J I �( r��►G� �I ° City/State/Zip: l' Phone#: 7fT :�l a �1'2 :x} I —, Are you an employer?Cheelc the appropxiatebox: Type of project(required): em to ees full and/or part time).* 7, ❑NeW'donstruct[on 1.�I am a employer with P 2.�❑ amI a a sole proprietor or partnership and have no employees Working for me in $, Remo deliTig any capacity.[No workers'comp.insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole j proprietors with no employees. 12 []Plumbing repairs or additions s.❑I am a general contractor and I have hiredthe sub-contractors listed onthe attached sheet. 13%Ej Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.] 14, 1 Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,p(4),and we have rio employees.[No workers'comp.insurance required.] Any applicant that checks box41 must also fill out the section below showing their workers'compensation policy information. Homeownerswho submit-this check this tiox�st affidavit an additional ic�ating they are shcot showing the name of theoing all work pd then hire contractotside rs and state whether or,s must submit a now nOthoseenf ties have such. Contractors employees. Hthe sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer tliatisprovidingworliers'compensation insurancefor°my employees. Pelow is tliepolicy andyoti site information. Insurance Company Name: _4A0J - 19) 5� t ), Expiration Date: Policy##or Self ins.Lie.#: J City/State/Zip Job Site Address: r - i� A/I ,Q : �� d/ c`3r1C�1'' ' Attach a copy of the workers, compensation policy declaration page(showing the policy er and expiration date). . olation punishable by a filib up to$1,500-00 Failure to secure coverage as requir as ivier ld enalties in the form of STOP25A is a criminal rWORK-ORDER and a fine of up to $250.00 a and/or one-year imprisonment,as p ay be forwarded to the Office of Iuvestigations of the DIA for insurance day against the violator.A copy of this statement m coverage verification. X do Hereby c ti,fy under'the ins n hies ofperjury that the information provided wave is true and correct lop Date: _ _--- Si ature: Phone#: this area,to he completed by city or town official. Offzcia se only. Do not write in Permit/License# City or Town: Issuing Authority(circle one): i 1.Board of Ifealth 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: . . AOUOkkkL H dF U$kkkCNd§k.:TTS \ �d ) »�o#:� . \ ISSUES THE FOLLOWE G \E SE S A k- \U:\M L C I s/ "RE, - v:»a� , « J fE \BROWN /\ <2 } \Dƒ « /T \\ d7/ \_\ 960-47ƒd 3 2 7 3 7/ / \� , . : a «v. . .3dd \