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Home My WebLink AboutWiring Permit - Permits #12437-1 - 890 JOHNSON STREET 6/30/2015 Date..... .� / ........... �r10HTl� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1-4 BQgCHUS� This certifies that � .............................................................................•........................... has permission to perform r � f wiringin the building of...............::.......... ve..... . .............................................................. � � C e-,� a � ........,No h Andover,Mass. at ...............�............ ..... ............................. Fee. &/ .......Lic.No. "� of//+`/�/ ........... ELECTR CAL SPECTOR Check# r r. Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co (MXE ) �CMR12.100 (PLEASE TRLYTININK OR TYPEALL 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) \:T1Dhn,5Jo 7— Owner or Tenant &ck I CL Telephone No. Owner's Address yy, Is this permit in conjunction with a building permit? Yes No El (Check AP ropriate]3ox) Purpose of Building Utility Authorization Existing Service /,J') Amps lv26 1.2X'0 Volts Overhead 1=1 UndgrdF] No.of Meters New Service Amps Volts Overhead FtF__"Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (t 4V 61 (<k1l 4 041,0 (jPQj,-eh c;iO()044�2 itompletion of the followingtable may be waived by the Inspector of Wires. No. o 4 y No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Trans Total formers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above Ei In- El NO,0 TT;mergency Lighting grud. grnd. Battery Units No.of Receptacle Outlets 5 No.of Oil Burners FIRE ALARMS lNo. of Zones No.of Switches No.of Gas Burners No. of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons HeatPump .......... .......... No.of Self-Contained No. of Waste Disposers Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal El Other Connection No.of Dryers Security Systems:* Heating Appliances KW No.of Devices or Equivalent No. of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent No.HydromassageBatlitubs No.of Motors Total IIP 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 MEC 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 co i in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSUIRANCE, BOND El OTHER El (Specify:) I certify, under thepains and Venalties ofpeijuiy,that the information on this application is true and complete. FIRM NAME:_ Brlai LIC.NO.: Licensee: Signature LIC.NO.: (If applicable, enter "exeinpt"in the licpsymber line.) , Bus.Tel.No.: 2!�� -1 vg ya3 -�Sj4 Address: �� '7(to 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 coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)El owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 1 Now — Q 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 shall 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 Ins ection Pass E Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Failed Re-Inspection Required($.) ❑ Pass r Inspectors Comments: f i f Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments :Inspectors Signature: Date: C}t7GH MSP TION: ass m Failed 0 Re-Inspection Required($.) ❑ 5.'eCtors Comments: i pectors Signature: Date: 7 e lJ INSPECTION: Failed � Re-Inspection Required($.) ❑ actors Comments: Ctors Signature: Date: 04HOL.p .,,TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts f Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name(Business/Organization/Individual): Address: City/State/Zip: ��Gr�;7i i NI}r` 636e,. Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑1 am a employer with 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. Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition 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 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.E]Roof repairs • These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other oyees.[No workers'comp,insurance required.] 152,§1(4),and we have no.�D41 *Any applicant that checks box#1 must also till 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 thepolicy and job site information. Insurance Company Name: Policy#or Self-ins,Lie.#: 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 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 hereby certify under the4tdns audpenalties ofperjury that the information provided above is true and correct. Sipnature;A Date: 6/1 dlr � Phone# 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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: . :ommo'NWEALTH'OF MASSACHUSETTS ELECTR1'CfANS.. ISSUES THE. FOLLOWING LICENSE AS--A,' REGISTERED MASTERELECTRICiAN BR;I AN M BOUCHER SR =z zw 2 TAMARpCIC Rb' Z `O ,J ! 1AisTOW . . NH 03865- 2774 1643;. A ' 0 7/3 %16 77997