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Home My WebLink Aboutwiring permit - Permits #13125 - 743 JOHNSON STREET 2/25/2015 Date W Ei. ! RrM�yc TOWN OF NORTH ANDOVER PERMIT FOR WIRING ! �`48gCMu`�� u � This certifies that ............ Vu � i has permission to perform �,.,. q .... wiring in the building of ..°.�...'�. ......................................................... ............. at ....,. 4 `...; ........ North Andover,Mass. ... Fee . :................Lic.No z�`..��. .. ... . INSPEECTORCTOR�.l`4 ELECTRICAL J i Check#" "J I Commonwealth ol VamacLmth Official Use Only Permit No. Apartment"13ie S.�Pvicej 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),527 CMR 12.00 (PLEASE, PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: ClA 9 h 4(0 C e L To the Inspe'clor of ires: By this application the undersigne gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Ie t:i C, Telephone No. Owner's Address 2ZL Z) Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building el inc it-- Utility Authorization No. -vice -head ❑ Undgrd ❑ No.of Meters Existing Service Amps Volts Overhead New Service Amps Volts OverheadF] Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Conipletion of the table may be waived by the Inspector of 147ires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- N-0.of EmergencyLighting No.of Luminaires Swimming Pool grid. ❑ gi-nd. El Battery Units kr No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches NV Tons No.of Detection and of Gas Initiating Devices Devices No.of Ranges No.of Air Cond. Tot No.of Aler ngtial Heat Pump T KW No.i SedNo.of Waste Disposers ...........Totals: Deteion/Alerting DevicesRMnicpalElOther No.of Dishwashers Space/Area Heating KW Loc ❑ Connection urity Systems: No.of Dryers Heating Appliances KW Sec No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters 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 itdesired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: (1 0 p, f2 )42,11,e Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE AGE: 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 n OTHER F e,"q t110 I (Specify. Jug— I I , I certify,under the pains and penalties t?fperjmy,that the information 0 t lis(1�1)fication is true and coinlVete. FIRM NAME: L6,11()fl, LIC.NO.:/7_ 36_`/`/" Licensee: Signature (If applicable, enter "ex ggipt"in the license munber line.) h� LIC.NO.:6 Bus.Tel.No.: 67—a' P '� u Address: r /1411 /"Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"I 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)F]owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ V, The Commonwealth of Massachusetts Department of IndustrialACCidents ::....:.: .µ Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): n Address; City/State/Zip: � �Jv'f��r � cr ,�, � Phone #: , r 7-- 7, -3 _ Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 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 $• Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance.) required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11. Plumbing '3.❑ I am a homeowner doing all.work repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §l(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 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. #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 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. 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 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 ce7//n- nder the pains and penalties of perjury that the information provided above is trace and correct. Signature: Date: ,7 Phone#: (r�5 p' ,-j ., Z > 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#: • • M $$ Cys ... SSUES C`t 'Fpt„�pWtNG. f � -URNEY tCFlVS E -T t G�°Ate M y' LEONARD "" j l DSR EXsj co TER.. MEN y A o 1844_