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Home My WebLink AboutWiring Permit - Permits #11446 - 140 JOHNNY CAKE STREET 3/6/2013 Date. .'.'; ... ......�.................. 40RTh A TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 88ACHUs� This certifies that ' ... .... L _ .................... . has permission to perform ..:..... ..... t P,' wiring in the building of.� U. ' ........I.........I................. a r �4'� North Andover,Mass. at ... ........ ............... , �� p i 1 Fee,,F� Lic.No. .�...�.�F. . .• 19LEyC'IRICAL INSPECTOR �r Check# - �RO a�� fa�iud O&cial Usc Only �eparfa�rrrfa�.�`ira Jaivre� I'cnaitNo.�� BOARD OF FIRE PREVENTION REGULATIONS O �and Fee eked P�e (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Ali work to 5e perlimmed iu with dwM03sm0hUstUSEWcWcd Code R7 OjM 12-09 (PL&dSEPRINT XBVK OR TYPEAU NPOR1tdAITOV City or Taws of-. frP �,yam nspector of yYu ter. By this application the undersigned gives nnttcet of his or her intention to To the I Location(Street&Number} F alectritl work dcscnl�si below. fry+ Owner orTenant Owner's Address _ ' ' Telephone No. Is ties permit in conjunction with a building peraut. Yes ❑ No Purpose of Buildin � Beck AFPropriate Boz) g Utility Authorization No. Bsisdag Service Amps yo/ � I� Overhead ElUn$ �d Q No-ofineter., New Service Amps I Volts Overhead❑ Undgrd Number of Feeders and Ampacity ❑ lVo.of Meters Location and Nature of Proposed Electrical Work: 7•rckla� �O 'r thee► - tabletn be t+luived thel oro mires No.of Recessed Luminaires ITNo.of Cell.-Susp(paddle)Fans - a.of To#a No.of Luminaire Outlets Transformers KVA No,of Hot Tubs Generators ICVA No.of Luminaim Swbnnhlg Fooi CJ © a.o ergency g d- Ba Dnits No.of Receptacle Outlets No.of(M Burners AY.ARMS No.of Zones Na.ofSwitehes No.of Gas Borneo No.of n aill No.of Ranges No.ofAir Cend. TO - Device Tons Na:ofAiert'mg Devices No.of Waste DisPosers Heat Toia>s- er ors o,o Alertin Devices No.of Dishwashers SpacdlArea Heating RW nmiclpal �t'a►rmectlou ❑Ufh� No.of Dryers H`eatiug Appliances Na.o ater o.of 0. KW No.of�or ivAleat Heaters Isigns Ballnsits Data WiriBg; Na.of Devices or E No.Hydromarssage Bathtubs 1NO.of Motors Total HP ecomMUM cattoas 1 firingg-ivalent OTHIJR: No.of Devices or ' alent Estucated Value o€Electrical Woric adduianat detmPifdertr orar ragztu ed by the Impecror of tires. Work.to Start: men requ�by mtmicipaI policy.} Insgec#ions t+a be requested is aaa7rdanee with IsdL�C R,&IQ and upon complexion. INSDRANC7 COVERAGE: UnIssswalved by the owner,no permit for the peafwmar=of electrical work may issue unless the licensee groyides jnoofof liability insurance ineiudma"ifmf QPeruflonA coverage or its substantial equivalent. The uadasigaed certifies that such caverage is in farce,and has eahibdtad Proof ofSame to the permit issuing outer CHECK ONE: INSURANCE §fi BOND ❑ O17Hf R ❑ (SpecifS"-) I c-ftf3►,wrdsr the pahv mdpeaalfies ofpcd irry,deaf the hyfarauatiara a 's. pT 'air is true and rotnptde FIRM NAME- r �E1f!D t:i.i i.�'!z:CAL 4WA i !{�11,A44, t' LIC.NO. Licensee: 0Rv it7 €, (Ilapplirnhl��rer " �m tlee license "Si��re_-__ r _-- LIC NO.: j J 16.3 t eaurrbe,Caraj l.No.• `l l -Z F� Address: _ 3� t C'4 is �T 7Wj{�D}", N77CYC� Bus.Te s1*. 144 *Per M-G.L.i~I47,s.57-bI,seemity wmlc Alt:Tel.No;,�b �T� 73 7` T tofPu6lic SafetyaS"Ltccase; Lim No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does,rathaw the liability insurance covetagc iiormall rrequired bOwner/Aylaw. By my Signature berow,I herabywaive this mq�lemeaL I am the(check one ❑owmee ❑owner's a y t Signature Telephone No. 1 'a L ., .- �r-�� o , � . '� �� .�, .-�.. j ' The Commonwealth of Massachusetts r Print Farm DepanWzenf of IandsaWalAeeidenn —tea a= office oflnvestzgafiens I Congress Sfre4 S`z&e.I00 .BosM.%M4 02114'20I7 -.._ www-mass govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Eleddeians/PInmbers A_pplicant Information Please Print Lepjbly Name(Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC Address_ 87 BELMONT ST Gity/S1de/Zip: NORTH ANDOVER,MA.01845 Phone#-- 978-682-6262 Are you an employer?Check the appropriate box: Type of (required): ro 1-Q I am a employer with 7 4. ❑I am a general contractor and I p ) employees(full and/or part-time)_* have hired the sub-contractors 6. ❑New construction 2 Q 1 am a sole proprietor or partner- listed on the attached sheeL 7. []Remodeling ship and have no employees These sub-contractors have g- ❑Demolition worlang for mein any rapacity employees and have workers' 9 Q Budding addition [No workers'comp.insurance comp.insurance i required_] 5.❑ We are a corporation and its I O j jl Electrical repairs oradditions 3.❑lam a homeowner doing all work offices have exerrcised their 1 i-n Plurribing repairs or additions myself[No workers comp right of exemption per MGL 12Q Roof repairs fl• insurance require c-152,§1(4),and we have no employees_[No workers' 1311 Other comp-insurance required-] ;Arty applignt that checks box#I must also fil[out the section below showing their worloew compensation policy infonnatior- 13airieowneis who submit this affidavit indicating they are doing all work and then hire outside ccmtractocs must submit a new affidavit indicating sucn. *contractors that check this box must attached an additioiml sheet showing the name of the sub-contractors and state whether or not those entities have employees. Tf the sub conductors have empioyee�they vwst Provide their workers'comp.policy number. 1 am an employer#tof is pravidmg workers'compensoXion�irarsurance in for my employees Below is tJteporrcy and job site formation. Insurance Company Name.. THE HARTFORD Policy#or Self-ins.Lic.#: 08 WEC C18293 Expiration Date: MARCH 1,2013 Job Site Address:_ /410 7� r , City/State/Zip "'�, A �y . Gam. 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 ofMGL 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 fo ns cc c verage verification. do lreneby of that the in anrursion provided ab ve is Prue and corned _ . r - - ------_ . _ r � , Phone# 978-6$2-6262 Of`icr`at use only. Do not write in this area.to be completed by city ortowrr officiaL City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3 Cidiy/i'own Clerk 4-Electrical Inspector 5.plumbing Inspector 6.Other CantactPerson- Phone#: