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Home My WebLink AboutWiring Permit - Permits #12755 - 22 INGLEWOOD STREET 9/18/2014 Date �.a .+.......... e O� &ORTH gti0 TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING * alil I t o :4• v Ziq °+•io. q4 BgACHU`�� _ This certifies that 1° `1 '. A . .� :... � rl . .. has permission to perform �'�`� " ....vt V ...0.p ........................................................................ wiring in the building of................. F � ,g" ................North Andover,Mass. at m r a �. 9 Fee .. 9..........Lie. No.-I-L'':4, .6 EL r ...... ... ....... . . ........................ ECT.......RIC..ALINSPECTO............R Check# �� (CornrnoruveaR of t//aieac1twetti Official Use Only cc Permit No. I 2epartment of ire Service 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.. V o y- 8\� 4:,(rt°1h(�P,t�' To tJ�e Inspector of Wires: By this application the undersigned gives notice of/his or her intention to perform the electrical work described below. Location(Street& Number) C;)n9 J-1 !1°t o00 d :4 Owner or Tenant ai-t L 2S 14,1 Telephone No. Owner's Address Is this permit in conjunction with a uilding permit? Yes No ❑ (Check Appropriate Box) Purpose of Building JG eS'&klfyj 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 Locat-io' an^d Nature .of,Proposed Electrical Work: `Da t1 t'w0U Completion of the.following tabte rna y be waived by the Inspector of lFires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total l� Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In-rnd. Bat❑ o.ote Emergency ig mg rnd. y Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices No.of Waste Disposers Heat PumpI.Number Tons KW No.of Self-Contained p Totals . Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection ) Heating Appliances Security Systems:* No.of Dyers g PP KW No.of Devices or Equivalent No.of Water No.of No,of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent — dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: No.H y g No.of Devices or Equivalent Y OTHER: GO Attach additional detail if desired,or as required by the Inspector of Ivires. ` Estimated Value of Electrical Work: (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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under Ifiepains atttl enalties of perjury,that the information on this application is trite and complete. _ FIRM NAME: C�� C.�� C�(1 LIC.NO.: �( � v ❑�.- (Ifapplcab er 'ex en`in�t'helilice se t tuber line.) Signature Bus.Tel.No.:O.: / 101'S Address: J`IG L t - (- �� W�/ I 3 Z— Alt.Tel.No. *Per M.G.L.c. 147,s.57-61,securityt work requires Department 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 PERMIT FEE: $ Signature Telephone No. www.rnass.gowata Workers' Compensation Insurance Affidavit: General Businesses Print Le ibl A licant Information `Business/Organization Name:--�) ' N = Address: 9 -N � C, �k/ Phone#: City/State/Zip: �7 Business Type(required): ri. re you an employer?Checic the appropriate box: 5 Retail ❑ I am a employer with employees(full and/part-time)." 6. ❑ Restaurant/Bar/Eating Establishment . I am a sole proprietor or partnership and have no 7• [] Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. g Non-profit ' [No workers' comp.insurance required] 9 Entertainment 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152,§1(4),and we have 10 fl Manufacturing no employees. [No workers' comp. insurance required]** 1 l.❑ Health Care / 4.❑ We are a non-profit organization,staffed by volunteers, 12. Other ';�•-/ J�/ �� with no employees. [No workers' comp. insurance req.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organi-ration should check box#I. jam an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lie.# Expiration Date: 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 e. 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 pains andpenalties ofpeijnry that the information provided above is true and correct. elp Sitrnatute Co�-� �'-�- Date: Phone# Official use only. Do not write in this area,to be completed by city or town offrcial CW ox•Tovrn: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5, Selectmen's Office 6. other Contact Person: Phone#: "\,J J t < OMMONWEALTH OF MASSAGHUSETmam TS_ ® . _, BOAHD:01= _s EL.--CTKICIANS ISSUES THE FOLLOWING `LICENSE i AS A E's JOU ELECTRICIAN AATR ICK T RYAN z k3W -9 HALLOWA.' iN !z NORTH BOROUGH MA 0 1532 2303