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HomeMy WebLinkAboutWiring Permit - Permits #11963 - 60 INGALLS STREET 10/25/2013 Date ........... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING i 88�CHUg� h G `. This certifies .......... _ f ...... .j.. ..... ......... ....................................... 4 has permission to perform - G 6 e wiring in the building of f........ ........ ` ......... ................... at K ... :, ,. . . ................. o4rM rth And ..�. 1 Fee �...3:p�.�' � Lie.No, �............�� f � , ELE CAL INSPECTOR Check# H cf Commonwealth of Massachusetts Official SP Nly ur NO Department of Fire Services m pe Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. t/qqj leave blank)(L APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(])VfEC), "27 CNIY12.00 (PL-EASE PPJj'VT IN INK OR TYPE A4 fjVF RiVL- 4 IV) Date: City or Towu of: /v�rt4 To the Inspector oj',WireS,, By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number)K-o s J7� Owner or Tenant S1111411 0 A- Owner's Address etr�a,7/0/f- Telephone No. Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building�u/r/-Z%'1 � Utility Authorization No. Existing Service Amps Volts Overhead Undgrd No. of Meters Q—: Nleff.dPX%igg Amps Volts Overhead Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the follom.n table may be waived by the AsZ!octor of Wires. ' No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle)Fans No.of Total —- Transformers KVA No.of Lighting Outlets No. of Hot Tubs Generators KYA f.E No.of Lighting Fixtures Swimming Pool Above n- 0.o mergency 0glinnig lrykd. rud. No.of Receptacle Outlets No. of Oil Burners FM ALARMS No, a f Z(D nes No.of Switches No. of Gas Burners No.of Detection and No.of Ranges No. of Air Cond. 0 nsTotal No.of Alerting Devices ----I--- , -1 No.of Waste Disposers Heat Pump NumberKW No.of Self-Contained Totals: I. !=Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 11 Cannection No. of Dryers Heating Appliances KW Security Systems: No.of Water No.of No.of — No.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: —1-_No,of Devices or Equiva ent No. Hydromassage Bathtubs No. of Motors 'Total EIP Telecommunication No.of Devices OTHER: L Attach additional detail if desired,or as required by the Inspector of Wires, 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 pen-nit issuing office. CHECK ONE: INSURANCE BOND 0 OTHER [I (Specify) Estimated Value.e of Electric I Work: (When required by municipal policy.) (Depi50ori Date) rrl�d perjury,uc'J� Work to Stan: o �Z J-, Inspections to be requested in accordance with MEC Rule 10, and upon completion. 7 I certify, under r e p ins an penalties ofpe that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee:�0. I Ts A�kfs Aes - -- Signature LIC.NO•.: (ffapplicable,enter " 11. - exempt th Z' b ,Vetcense,yum Address: - 4 _ 1�'V- Bus.Tel. No. Alt,Tel. No— OWNER'S INSURANCE WAIVER: I am aware tffat the Licensee do-es not hapv the liability insurance cover-age., normally required by law. By my signature below, I hereby waive this requirement. I am the(check one 0 owner 13 ovmer.,5-a en"t Owner/Agent , Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations L r (j1 8 , 01 Congress Street, Suite 100 Boston, MA 02114-2017 wnw.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): L, kz. �/ S G5 _ Address: 2 9 ;ae- `�7 City/State/Zip: LYYd3Phone #: Are you an employer? Chec c the appropriate box: Type of project(required): lam a employer with �� 4. ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New constriction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. employees and have workers' 9, F-IBuilaing addition. [No workers' comp. insurance comp. insurance.1 requir ed.]u 5. ❑ We are a corporation and its Electrical repairs or additions ] 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ 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#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-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 in formation. Insurance Company Name: Policy#or Self-ins. Lic. #: ® 02.E (7 4:::$6 L15 4 //3 Expiration Date: Job Site Address: c�0 ��9 -��f �� City/State/Zip:/1��r 11 aye y 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. oe I'do hereby certify under the pai d penalties of perju a information provided above is try and correct. Signature: Date: 3 Phone#: 1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: IT 1 Y) Y© + ONN� f'E w-gg bw, WE �3 } " - IIt L r 4 f t-: - 'uty1a1 :'CF17J\ LL..iVV4i( '+?:X.:r >^�._ Fj.Yi =w:: { -�?;K:....-"ya `�1F,1?.-a".. .,.t,,....Y,. i �� f�ws� £r,SNT.'��=�'_'' `:'�:1 ��f��,ss'} a k-.: -f:•'�:. :�'�t;a El 9j"�drrg�-�-',i�j1��;�-�'�_ .a.�,o_ •.i•��Fr^2{tLt���-^3"-. �'y-+, S'�=...'�. I .�d3'r ITf� lt�� y?. XGiu•Ia l'J�'�u r S I TE D MA-.STE'R LE�'ff � G7AN 4 �y( }ilst; E PCPECI STul you; 1 Y` ' o 18 44_406 i48 A 44$ 3�:rr�