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Home My WebLink Aboutwiring permit - Permits #12448-1 - 458 JOHNSON STREET 7/2/2015 /Date. .... -............. ..... I NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,l e CHUg�� f This certifies that ............ °................. p �� .."�...� . ....... . ::......... �..h...../has permission to perform ...... , .. ...�.'......... . ' � � e wiring in the building of.. J44 9.�� ... � d at . �...:.................................................................. ° f.NorthnAndover�Mass. Fee. Lic. No, P .. € . . . t::....................... ...zr.................................................................. ELECTRICAL INSPECTOR Check# d 1 ® � Cornmonwealdi of Maddacliudetb Official Use Only Permit No. 2-partnwnt o�.�`ire�eruiced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMITT P 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 AL IN RAMTION) Date: '71///,S- City or Town of: rjh To the Inspector of Wires: By this application the undersigned gives notice of his or her intentio, to perform the electrical work described below. Location(Street&Number) 7 v� �1agsir) 5:,KV _ Owner or Tenant Telephone No. ',� 7 y/1/0— Y/ Owner's Address ` K e-- Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service og00 Amps /d�11 Volts Overhead Undgrd❑ No.of Meters / New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity )) G Location and Nature of Proposed Electrical Work: c'P 5>s nix - CAS" S Com leNon ofthefiollowing table inay be waived by the Inspector of Wires, f Ceil:Susp.(Paddle)Fans o.of Total No.of Recessed Luminaires No.o �� Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALA101S No.of:Cones 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 el No.of Waste Disposers Heat Pump ....um._er' ons o.o elf- ontained Totals: . ""' "'"* _................... 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 KW No.o 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 if desired or as required by the Inspector o,f I•Pires. Estimated Value of Ell cal Work: (When required by municipal policy.) Work to Start: b� f J_ 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE t BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,d�ra�t tlje inf!2nilatfon on this application is trite and complete. FIRM NAME: Qa�, r f� Ll c G i /7rU�=�A,Yk;r,6 LIC.NO.: Licensee: A11c./,5:e1 Signature '�' ' LIC.NO.:,:�J' D`y= (Ifapplicable,enter"exempt"i the license number lin .) Bus.Tel.No.: Address: /,1,k7rrr i; ,x3. ;. )"y, , ,M9 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-6 ,security work requires Deparfinent 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. PERMXT FEE.$ The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston,MA 02111 UT www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: q, c2°�/� k&-( J 9 City/State/Zip: a"m ��r/� / Cj��`� _ Phone#: /�� Are you an employer?Check the appropriate box: Type of project(required): 1 I am a with employer 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. ❑ New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers'comp. ❑ Building addition [No workers' comp.insurance comp.insurance.$ . (�5 We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.El I required.] a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I 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. 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 the policy and job site information. 600V6__) Insurance Company Name: — Policy#or Self-ins.Lic.#: � /Y( 7 Expiration Date: /C Job Site Address: S�nS U City/State/Zip: ////, W��P/` / � (*.e.-ls 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 certify under the p 'ns penal ' s of perjury that the information provided above is true and correct: St afore: 'G� -''2 Date: 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#: