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Home My WebLink AboutWiring Permit - Permits #13238-1 - 84 JOHNSON STREET 3/31/2016 , G Dates �. ........... F NORrM,�O o o� TOWN OF NORTH ANDOVER * * PERMIT FOR WIRING CHUs�t `e This certifies that has permission to perform_ @ q g ��d Ca,e Wiring in the building of..... " " at ..... . ............. . ...,North Andover,Mass. Fee... �.. ..........Lie.No.�5 ...................... A ELECTRICAL INSPECTOR ............ Check# Official Use Only �nurer�lLh o I!/ue3ac�iu9e ( I c� Permit No. I ,ACJe�rar`i�atr�'o��ir�c�arulce� Occupancy and Pee Checked 130ARD OF FIRE PREVENTION REGULATIONS ev.1/071 keavebiank APPLICATION q p� TIPERMIT tl TPERFORM ELECTRICAL r I~I�.S it ark to be perfortned in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR 71 ALL 14VFORMA7'IOt� To s ' o the In ector^o Wires: City or Town of. ,� � Y this ppundersigned gives a of his or her rnten e tion to perform the electrical work describe below. Location(Street&&Number) Hatt Telephone No., d Owner'or Tenant � � �° (' " Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Apprcr►priate Pox) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Newer Amps / Volts overhead❑ Undgrd Q No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work-, Com letion o the followingtable m be waived b the ins ector o Wires. No.of Total No,of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hof Tubs Generators I'`VA' ;A1gve n_ o ne�rgency ig ngNo.of Luminaires Swimming Poolnd. ❑ d. ❑ Bane Units No.of Receptacle Outlets No.of 0.11 Burners FIRE ALARMS Na.of banes o.o etechon an No.of Switches No.of Gas Burners Initiatin Devices 0 Ko.of Alerting Devices ` No.of Ranges No.of Air Cond. Tons No.of Waste Disposers a 1p -wp�b�r Ton o.o e f-Cants ne Detection/Alertin 3r Devices Local unicipal Other No.of Dishwashers Space/Area Hosting ICW ❑ Connection El Heating Appliances KW 7eur.' fy yystents:No.of Dryers .of Devices or Equivalent No.of Water tea•of 0.0 Data Wiring: Heaters Si s Ballasts No.of Devices or E trivalent elecremnxumcatzares irrng: 7�7 ,n »tr»funk OTHER: M, „,..... Attach additional detail tf desired,or as required by the inspector of Wires. Estimated Value of Electrical Work (When required by municipal policy.) Work to Start ' � "�;•s°llt)' 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 BOND ❑ OTHER ❑ (Specify.,) I certify,under the pains and hies ofper,jury,that the information on this tapplication is true and complete, g I,I C.NOS S 6 S 0a FIRM NAME: Aries ELectra.cal Service and C.on,txo1s , C Licensee: Nor and Michaud Si nattr.� NO.. le, r::..:.:. _. �__ . .» (If applicable,enter exem t'in the license number line„► Bps,Tel.No.: 9'Ir fil �,R 7 0 5'44 Address: 290 Hroadvay su3.te 1'17 Methuen ma 01844 US.Tel,No,- *Psi M.G.L.c. 147,s. S7-tit,security work requires Department of Public Safety"S"License: Lic,No, OWNER'S INSURANCE WAr"R. I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. 13y my signature below,I hereby waive this requirement, Tam the(check one Q owner ❑owner's agent, Owner/AgentSignature Telephone No. PERMIT FEE: $ . The Commonwealth of Massachusetts Department of Industrial Accidents IVOffice of Investigations 600 Washington Street Boston,MA 02111 �T_ J, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/organization/Individual): C � -- r- Address: 2 170 _l tAd r ,�_ z %"f-" z/ City/State/Zip:�ie--T- l4/ ./d /'I toi 1 1/y Phone #: Are yo an employer?Check the appropriate box: Type of project(required): 1. i am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workers' comp.insurance. 9, Building addition working forme in any capacity. ❑ g [No workers' comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their required.] 11. Plumbing to airs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ❑ g • p myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t 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 their workers'comp.policy information. I am all employer that is providing workers'compensation insurance fir my employees. Below is the policy and f ob site information. / Insurance Company Name: A r, l 1 but Policy#or Self-ins.Lic # `-.-.ice/i1./C Expiration Date: ��<�� l •1� ol a "- ` r s Job Site Address City/State/Zip Ir` i � Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). o - -r W.��•��.—l— ,,,1�;-y-1 nnprrsunment,as well as civil penalties in the foof a rm ofa 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. a I do hereby certify under th ep. pains anpenalres of �rJ ry tdiat /witforna�l ionprovide d� above is true and correct. Signature: _ Dates w°e, � _ f Phone#: Official use only. Do not write ill 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M ft U# QU��fY� f 4( SETT QN COMMONWEALTH-OF _ 31/ ., 4 F S; SHE FUMING �&M . A� lmv ".T.-EgED MAS R :E E£,a R.I 42 APB:+> } " hsQR % wo 0 MICHAUD Via SAS a Iz dli0�487 22 1 5�5t A 47/3?� 3b166 ,J �.,