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Home My WebLink AboutWiring Permit - Permits #12648-1 - 30 KINGSTON STREET 9/8/2015 Date ...hs �. OF r10RT/y, 1 �?° � ��` .�•ti�o t TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING 8'®Cmus�( This certifies that..... ' t s has permi ............................. ssion to perform ....................... .... .......... .. \ p wiring in the building of..... .......... �.. �.� S............... ............ at .....�.................. . . . .. ......>NA ni Fee.. , .. .. Lie.No 6' over,Mass. .....it E .... .................ECMCAL INSPEO �\ Commonweak of Mamac4wetb �fficial Use Only Permit No. 2epartownt ol3ire Servicee 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(MEC) 27 CMR 1❑ ( PLEASE PRINT IN INK OR TYPE ALL fl FORMATION Date: City or Town of: /V- /7N�(�1�61 To the Inspector of Wires: By this application the undersigned gives nptice of his 4r her intention to perform the electrical work described below. Location (Street&Numbe b V,1 Owner or Tenant Telephone No. (�J Owner's Address .0 lV 1-11 Is this permit in conjunction with a building 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: �, /kjy� ��Z ACeq�, /well Completion of the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil.SP•(Paddle) Transs Paddle Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires swimming Pool Above ❑ In- ❑ o.o mergency Lighting g rnd. rnd. Satter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW Security Systems: ry No.of Devices or Equivalent No.of Water 1 ' No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: No.H 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 NEC 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 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and p nalties of perjury,that the information on this application is true and complete. ry FIRM NAME- LIC.NO.: � �1 Licensee: ` Signature C.NO.: _ (Ifapplicable,enter, ` empt"in t e icense number line.) J Bus.Tel.No.: Address: UI7,4/ `�— / / 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 cov required by law. By my signature below,I hereby waive this requirement. I am the(check one ❑owner Owner/Agent PERMIT F. Signature Telephone No. Xhe Commonwealth ofMassgchusetts z , Department ofIndlusiial-Aceldents d Z Congress Street,Suite 100 Boston,MA02114 2017 sy*ti4`e www.mass.gov/dia Wovkers'Compensation insurance Affidavit:Buildens/Coni;ractors/Tiectrlclans/Plumbers. TO BE,FILED WITH TBG PERM[TTINQ AUTHORITY. A Ticant Information /// Please Print Leibly Name(Business/organizationadividual):�� .Address: �7�rJ UO�it/ �✓ n4�� Phone##: l/ �7a �f city/state/zip: . . Areyou an employe*?Checkt&appxopriatebox: Type of project )Vequired): Q]I am a cmployerwith employees(full and/or part time).* 7. ❑New construction 2, am'a sole proprietor or partnership and have no employees working for me in 8. 0 Remo deliAg any capacity.[No workers'comp.insurance required] 9, ❑Demolition 1 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 ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12„❑Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance, ' �6 f]We are a corporation and its officers have exercisedtheir right of exemption perMG1,c. 14.El Other 152,§1(4),and we have ne employees.[No workers'comp,insurance required.] *Any applicant that checks iiox#1 must also fill out the section below showingtheirworkers'compensation policy information. .i Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. ?Contractors 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 rimst proyide their workers'comp.policy number. I am an employer Mat ispi'ovidingworkers'compensation insurance for my emplayees.'.below is thepokey andjob site information. Insurance Company Name: Policy#or Self ins,Lic.#: ExpirationDate: p Job Site Address: A — - 3 0" 1�( K�1� y�(141 City/State/Zip: / /,Z /y, Attach a copy of the Workers' coanpensatioii•policy declaration page(showingthe policynUmber and expiration elate). Failure to secure coverage as required under NML 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/iereby ee a under the 'ns andpenalties ofper/zrry that the informationprovided above is true and correct Signature: lq Date: Glj✓� Phone# / Z (of 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.JBuildingDepartm.ent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH'OF MASSACfWall iU ® ® ® ® ® aoa��s 0w= E EC `RI C1ANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ;f LECTRJ C!AN 'jam ROGERY BERGERON z]; 38 AUBURN W HA.VERHILL:: MA 01830 5004 j 26317 E. ... 07/31/16 8 12 ��,.� 99