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Home My WebLink AboutWiring Permit - Permits #11511 - 32 FOXHILL ROAD 4/10/2013 Date. ... .. ....... �..... I f BATH ; �°;•''';;'a TOWN OF NORTH ANDOVER PERMIT FOR WIRING rt BACHU9� This certifies that has permission to perform ...................................f.::�,r.............................................................. -wiring in the building of.......... a..................................................................... ��< t� North Andover Mass. at t:... E Fe . .�.................Lic.No. , z€ ................ EL96imcAL INSPHCMR �G Check# , Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. / jam'// Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: %❑9 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) za Owner or Tenant ,I Telephone No. Owner's Address '66LM C Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps /�7O /04�0 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: ,, et,-; �•�ih�t2 Com letion o the ollowin table maybe ivaivedby the Inspectorof Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires w Swimming Pool Above ❑ In- 1-1o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones ,� No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Disposers Heat Pum Number Tons KW No.of Self-Contained No.of Waste Dis p Totals I Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water Kam, 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 E uivalent OTHER: �l Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: L/!IC>C7 (When required by municipal policy.) Work to Start: /3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COV f RAGE: 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 the pains and penalties of perjury,that the information on this application is trite and complete. FIRM NAME: LIC.NO.:�C J__ Licensee: Signature LIC.NO.: (Ifapplicable,enter "exempt"in the license number h1n/e.),� // Bus.Tel.No.: Address: `l�ar c% �� ar l�h 1�r C4"rr r l tril 01�Y J� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security 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. n / u �— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PPrint Legibly Name(Business/Organization/Individual): /�� i�-7c�i1/ �G�`c�Gr,c •ZL Address: � City/State/Zip:,�//W� f 9 e1w,,, /yam Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.JULT am a employer with Z 4. ❑ 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. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. lectrical 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 12.❑Roof repairs insurance required.]t employees.[No workers' 131J Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 1s providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: ✓hIGr�aver �r��uyG n�c' C o Policy#or Self-ins.Lic.#: Expiration Date: l / Job Site Address:- h, ��" City/State/Zip:ZA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or onc;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 of perjury that the information provided above is true anti correct. - Signature� wit 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: ��--COMIMONVMALTH OFktASSAC ELECTRICIANS REGISTERED MASTER ELECTRICIarN ' ISSUES,THE ABOVE LICENSE TO: MICHAEL 'W DAMOUR 6 MOODY ST N ANDOVER MA 01845-1712,