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Home My WebLink AboutWiring permit - Permits #12651-1 - 28 KINGSTON STREET 9/8/2015 Date 1,►OR7l� 3? .•��,.:°tioo` TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,88ACHUg�� This certifies that .. ...•......••pp [¢ """"' has permission to perform wrong in the building of.. .Ed ................................................................ North Andover,Mass. .....Lic. ........ . E ...... . ....................... .................. ............. LEC MC;L INSPECI OR Check# (fommonwea&o f kamachudetb Official Use Only ccyy�� PermitNo. aLJepartment-13 ire Services BOARD OF FIRE PREVENTION REGULATIONS Ov.1/0a7cy and Fee Checked leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: 1V1'41ey00V e t- 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&Nu giber) Owner or Tenant Ja�p��o,� e elmtj A Telephone No �6 -t�5 q I Owner's Address Is this permit in con unction with 1i 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: � j % � P41vol Completion o the following table mav be waived by the Inspector of Wires, FNoof Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA Luminaire Outlets No.of Hot Tubs Generators 'VA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons K No.of Self-Contained Totals: .. ... I............... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water No.KW No.of No.of Data Wiring. Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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 verage 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 enalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: e v Signature LIC.NO.:o`er 317;�a (If applicable, enter" e p tJ3�h_gg tense num r line.)Address: Bus.Tel.No.: �� U / f f7 !/i,�1 �J Alt.Tel.No.: / 771 *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 coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one ❑owner ❑owner's agent.' Owner/Agent Signature Telephone No. PERMIT FEE. $ -fie Commonwealth of Hlqlssachuseifs Department of InelnsiWal.Aceldents u' _ Z Congress Street,Suite 100 Boston,MA 02114-2017' www.mass go v1dia, Wajrkers'Compensation lnsura-j�ce Affidavit:Buifdexs/Contractors[Eiectriciaus/Rlum)'oers- TO BE AILED WS�`1=[THE PERMtTTCI�T�•AUTJ�ORZ'z°Sz'. Ap licarat Inforrntation Please Print LedblY Name(Business/Organizationffndividual): / U� Address: URA/ Czar/state/Zip: i �Y �J G% Phone#: ��/ 1 Areyott an exployer?Checlrtlie appropriate hox; 'Type of project()•squired): 1. I am a employer with employees(full and/or part-time).* 7. [(New. construction 2, a sole proprietor or partnership and have no employees Working for me in 8. Remo delhig any capacity.[Noworkers'comp.insurance required] 9 El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.E]I am a homeowner andwilt be hiring contractors to conduct all work on my property. I will E]Electrical repairs or additions ensure That all contractors either have workers'compensation insurance or are sole 1L, proprietors with no em�loyees. 12..F[Plumbing repairs or additions 5.Q I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees andhave workers'comp.insnrance.t 14.El Other 6.❑We are a corporation and its ofCcers have exercisedtheir right of exemption perMGL G. 152,§1(4),andwe have na employees.[No workers'comp.insurance required.] *Any applicant tfiat checks box#i must also fill out the sectionbelow showingtheirworkers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such. YContractors that check this box must-attached an additional sheet showing the name of the sub contractors and state whether or not(hose entities have employees. If the sub-contractors have employees,they riiust provide their worlcers'comp.policy number. I am arz employer thattispid-piding workers'compensatior2 insurancefor my employees.' below is t/iepolicy arcd/o7a site information. Tnsman.ce Company Name: Policy#or Self ins,UG.#: Expiration Date: a Job Site A ddxess: / + r� '—� 1�� l 0/7/ , � City/State/Zip: ��4/y)21V Y' Attach.a copy of the workers'compepsation'polley declaration.page(shawiugthe polxcynurrabsr and expiration date}. Failure to secure coverage as required under MGL 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. I do h Awns ee under the wns andpenallies ofpelyuly that the information pr ovzayecl a7�overi is true n�reef Signature. Date: Phone# Official use only. Do notVrzte in this area,to he completed by city or totvrz official. City or Town: Permit/License 9 Issuing Authority(circle one): i 1..Board of Health 1 JBuildingDepartm.ent 3.City/Town Clerk 4.Electrical.Inspector 5.Plumlbingbspector 6.Other Contact Person: Phone 4: I ..COMMONWEALTH OF MASSACtiUSET�1'S ® ® ® me ® ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A 12EG JOURNEYMAN ELECT[2 ItC I AN '� ROGER<Y BE RGERON IZ ;.. ; . : 38 AUBUE?N HA.UERHI LL . ° MA ot830 5004 26317 E .... 07/311:,,)� .... g �2 ..