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Home My WebLink AboutWiring Permit - Permits #13120-1 - 135 JOHNNY CAKE STREET 1/17/2016 Date..�.t..Ib ................ OF NORTH, TOWN OF NORTH ANDOVER i ° 9 PERMIT FOR WIRING $BACHU9 This certifies that f ...... ...... ................................................................ C. has permission to perform � �:....�.r� ...... a� � z - r wiring the building of....Ct,........................................ �. North Andover,Mass. .................................. Fee,tf .. ..................Lie.No ........ ELECTRICAL INSPECTOR Check# f � ' �� Commonwealth ®f Massachusetts Official Use Only Department Fire e ie Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIOI'S [Rev.1/07) (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(AMC 527 12.00 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspe for of YWires: By this application the undersigned notice of his or her intention to perform the electrical work described below. e� Location(Street&Number) (1-r)141,YA)461ME Owner or Tenant c 1 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building_' Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig tmg rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Total g Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: ...."""... Detection/Ale ting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Sec No.o Devices l 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 if desired,or as required by the Inspector of Wires. Estimated'Value of Electrical Work: 70 ' i o( (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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: NCE [I BOND El OTHER ❑ (Specify:) X certify, unt r the pain and penalties pet ju ,t at the information on this application is true and complete. FIRM NA LIC.NO.: , Licensee: 7c7 Signatur v _ LTC.NO.: (If applicable, ter " mpt"in the license number 4us.Tel.No.:�� , Address: Alt.Tel.No.- *Per M.G.L c. 47,s.57-61,security work requires Department of Public Safety"S"License: Lie.No.� OWNER'S IN ANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required b aw. By y signature ,elow,l hereby waive this requirement. I am the(check one)❑owner ❑owne 's agent. Ownerir at ' Tele hone No. �S - 'r> PE.ZMIT FEE. Signature p i ❑ 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 shall1be uniform throughout the Commonwealth,and applications shalt be filed on the prescribed form.After a permit application has been accepte I 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 corporatio.i 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.1a3,§3L. Permits shall he limited as to the time of ongoing construction ,tivity,and may be deemed by the Inspector of Wires abandoned and invalid if he L. or she has determined that the authorized work has not con (nced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work sl'ill be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated ort the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of2010 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 Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH IN ECTION: Pass M V/ Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of lndustrialAccidents 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 I Please Print Le ibl NaMe, (Bu �D,siness/Organization/Individual): ' `C 1. Address: p�,City/State/Zip: 44due7e � Phtoyoxle#: Are you an employer?Cheek the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in R modeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑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.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs • These sub-contractors have employees and have workers'comp.insurance.$ �Te are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'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. 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-coriiractors 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 anti job site information. Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: I fj Job Site Address: �?)�; tj City/State/Zip:teoA- Attach a copy of the workers' compensation p licy 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 the pains andpenalties ofperluiy that the information provided above is true and correct. Signature: 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#: g g r. .. . :COMMONWEALTH OF MASS ACHUSETTS. ... i f LEC.- V84 Cl*ANS ISSUES THE FOLL`OWING `LICENSE � ;JOURNEYMAN ELEC,TR I C I AN k" . a DRUID Car J KRAFTON , ; . al 93 CORK I UEAt! DR It?OSETT I,IH 03106 2419 l 348.1R .;.. .07/3] 1.6 .... a24095 4all d