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Home My WebLink AboutWirig Permit - Permits #12782 - 51 FOXHILL ROAD 10/2/2014 Date............................................� OF NORTfj q� TOWN OF NORTH ANDOVER o � PERMIT FOR WIRING gsACHUSE A This certifies that ............. fi �....:. ...'%�.:.; �. ..♦i f J?t.. r....................................... has permission to perform ............ :............r�..� �.......................................................... wiring in the building of............. e ' ................................................ at ........ ....��..:�....�.....a. ..�.k.:...........`�..,� :........................ North Andover,Mass. Fee.:. ` Lic.No, 11��. ... :: ..��L.,�� ,�: ...ff , ;ELECTRICAL INSPECTOR F Check# �� _ Print Form__ C0090= .ommonwea&o f Ma,3aachuaetb Official Use Only 77 cc�� Permit No. 14 2L.2 e, 2apartment ofcc77 ire Serviee� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION IELECTRICAL 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: 10/1/14 City or Town of. north andover To the 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)51 fox hill road Owner or Tenant Sue buchholz Telephone No. 9788289185 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building dwlling Utility Authorization No. Existing Service 200 Amps 120 / 240 Volts Overhead ❑ Undgrd❑✓ No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: wire 50 amp hot tub circuit to outdoor location and terminate with disconnect gfci rated Completion of thefiollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs 1 Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. Batte 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 No.of Alerting Devices g Tons No.of Waste Disposers Hear Pump Number Tons KW No.Detection/AlertingofSelf-Contained f-CotainDevices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water Kam, No.of No.of Data Wiring: Heaters 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 OTHER: Attach additional detail if desiredd,or-as required by the Inspector of Wires. Estimated Value of Electrical Work: 1100.00 (When required by mu ic' al policy.) Work to Start:10/1/14 Inspections to be requested in accordance with M C Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the perfor lance of electrical work may issue unless the licensee provides proof of liability insurance including"completed oper4tic,0 co rage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of sa;ad permit issuing office. CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (Specify: I certify,under the pains and penalties ofperjuty,that the information n•this n is true and complete. FIRM NAME: lance macinnis electric I LIC.NO.:21217a Licensee: lance macinnis Signature Z , LIC.NO.: (If applicable,enter "exempt"in the license manber line) Bus.Tel.No.:5087260802 Address: 12 locust street middleton ma 01949 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Department"of Publi e `S"License: Lie.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 Signature Telephone No. PERMIT FEE: $ The Commonwealth of 112"assachusetis Department of Industrial Accidents Office of Investigations 600 Washington Street . � Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A1) licant information Please Print Legibly Name (Business/Organization/Individual): lance macinnis Address: 12 locust street City/State/Zip: middleton ma 01949 Phone #: 5087260802 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 1 4. El 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. 1 Remodeling - ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9. IJ Building addition [No workers' comp. insurance 5. --- We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12JO Roof repairs insurance required.] t employees. [No workers' comp. insurance required.) 13. __ Other *,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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: the hartford Policy#or Self-ins. Lic.#: '37455e Expiration Date: 51 fox hill road north andover ma Job Site Address: City/State/Zip: Attach a copy of the w r rs' compensation policy declaration page(showing the policy number and expiration date). Failure to secure covera e a re uired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.0 an era ear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250,00 a y gatnst violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of tl DI for in ranee coverage verification. I do hereby a sn dig v the p s and penalties of perjury that the information:provided above is true and correct Si nature: Date: Phone#: 08 60802 Official use only. Do not ivyte 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#: MNWEA � ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS ,A REGISTERED MASTER .ELECT LANCE D MACINNIS w lu 12 LOCUST ST MID LETON MA oig4g-12o6 1217 A O/3I 1 024 w. �l , �, _