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Home My WebLink AboutWiring Permit - Permits #13293 - 0 FOULDS TERRACE 5/8/2015 Date. v ..................... . OF p►ORTh ��: : ,'• °oL TOWN OF [NORTH ANDOVER ° PERMIT FOR WIRING TY �ow4T'EG •(� CHU`�� R This certifies that ' ......... ......... .................................................... has permission to perform . ... ....� ....1'..... .. .:.. ..:...... wiring in the building of..... ....... ..."........ry .......: ...... ° .} E.......................................` ,., ass.Andover .................Lic. No '`� ... @ ....... .j :� ELECTRICALINSPECTo Lr Check# � }� (f1mmonweafilt ol Maijac1twetb Cifficial Use Only 2epartment ol-c7ire Service.4 Permit No. Occupancy and Fee Checked lug 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 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the ele tri I work described below. 77v Location(Street&Number) 70 .1 Owner or Tenant k, \Telephone No. Owner's Address Is this permit in corkituiction 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: /`4= , Completion qf the fibllowing 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 Generators KVA No.of Luminaires Swimming Pool Above [:] In- No-. ot Emergency Lighting Ri-nd. ❑ Rrnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS jNo.of Zones No.of Switches No.of Gas Burners No.of Detection and Total Initiating Devices No.of Ranges No.of Air Cond. Tons t,No.of Alerting Devices No.of Waste Disposers Heat Pump umber I'Ions K .......... No.of Self-Contained Totals: I................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local n Mun'c'pal n Other ge—eurity Connection No.of Dryers Heating Appliances KW No.of Equivalent No.of Water No.of No.of Data Wiring: Heaters KW signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Tele co�n►ttumcations Wiring: Na.of Devices or E uivalent OTHER: Attach additional delail if desired,oras required ki,the Inspector q1,14"ires. ............. 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 pen-nit issuing office. CHECK ONE: INSURANCE n BOND n OTHER n (Specify:) I certify, under the pains and penalties ofpeijiny,that tl e hifibrillatf'on on this application is true and complete. FIRM NAME: .-/ ,_ LTC.NO.: Licensee: Sig, LIC.NO.: ;j 20-5---14 (Ifopplicable,enter"exempt"in the license number line) Bus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"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)n owner El owner's age re nt. Owner/Agent -7 Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents R Office of Investigations k 600 Washington Street Boston, MA 02111 v www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Plea)se Name(Business/Organization/Individual): f , #U11 Address: i(rid \J City/State/Zip: , e(f r9 4)nter- Z (T)P11_ Phone#: Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 4. E] I am a general contractor and 1 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.EJ I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance. 10. Electrical repairs or additions required.] 5. EJ We are a corporation and its 3.El I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions MGL myself right of exemption per[No workers' comp. c. 152, §1(4),and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' 13.[:] Other comp.insurance required.L--J I *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. lContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. ` 11�' -Ure Insurance Company Name: ��-IOQVeJ Z,1,6 I Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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. I do hereby certify under the !,s aw,�01 d N* penal Ves of perjury that the information provided above is true and correct SigLiature: Date: Phan g#: 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#: X ' a Commonwealth of Ma ..setts Division of Registratiortr Board of Electr!aLE�te _ MICHAE I� 9 WAVE M n NORTH A Master Elec` 'arm FI 21705-A 07/31/2016N ~ " 008772 License No. Expiration Date. Serial No.