The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Permits #12539 - 706 FOSTER STREET 7/18/2014 Date.. .. ............ j NORTI� i °� •9"'° TOWN OF NORTH ANDOVER * PERMIT FOR WIRING { 'lye+•°+.i+,r Afig a �BACHUf+� kk This certifies that ........ � � .............[.�................ U�— has permission to perform .. � . � . ` ... wiring in the building of _ ...o_. .......: :.........`........•.�... i ................................................... �G� h Andover,Mass. at �... .. ...... ......... ............... FeeZ...:d................Lic. No 5.� .. .. .... .................... .................'................... ..... ELECTRICAL INSPECTOR Check# OfficialjJse Only Commonwealth of Massachusetts Permit No. Department of Fire Services 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(NEC),527 CMR 12.00 (PLEASE PMTINIArK OR TYPE ALL INFORMATION) Date: z's_)Ly, I B I&l 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) Owner or Tenant f\C11,•V"1 1—C)y Telephone No. Owner's Address & M E, Is this permit in conjunction with a building permit? Yes [I No D (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps volts OverheadF] Undgrd F] No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number-of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CDE, C,Iti EL 1,,,l =,"w n-yj,,S�E ELh�8r.L Completion of the followingtable may be waived by the Inspector of Wires. No.of No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei W050TE'ruergency Lighting grnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners Cg FIRE ALARMS No. of Zones No.of Switches No. of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Con d. Tons Tot No.of Alerting Devices al No. of Waste Disposers Heat Pump T_b�r],Tqns IKW No.of Self-Contained Totals: I ................I................ Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW F]Local Connection No.of Dryers Heating Appliances KW Security S Dystems:* No.of evices or Equivalent No.of Water KW 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 Enuivalent OTHER: Attach additional detail 1fdestred,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: !7__1 E3—1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: less 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 n BOND F] OTHER n (Specify:) Icerfify,iin(lei,iliepains and penalties ofpeijuiy,that the information on this application is true and complete. FIRM NAME: LIC,NO.: Licensee: Si nature LTC.NO.: V Bus.Tel.No.: (1fapplicable,enter "exempt"in the license number line) CA��Jft�� Address: 15''. GA1JX,'V1U ACX wj C�:&Q,59;) Alt.Tel.No.: *Per M.G.1,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)F1 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeAW NaMO Business/Or anization/fndividual . r Address: 15 GnAL.i _60 City/State/Zip:_ V, 1,4J,,JPhone#: 276 ,22 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2:° J 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.❑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 12.❑Roof repairs insurance required.]i employees. [No workers' 131J Other comp,insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i 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 joh site information. Insurance Company Name:. Policy#or Self ins.Lie.#: Expiration Date: Job Site Address, �e` City/State/Zip: V\JA 0 18,4 � 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 o. 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 WORD 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 and penalties of perjury that the information provided above is true and correct. - Si ature: '�� Date: iI 2C I t Phone#: a q E, 2 9 11 6221 Official use only. Do not write in this area,to he 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#: - n r • . • • - q.pb .)r n' �y ' 13i 5 (11 J l�y��t�r�arrur��ea��y ,�y��t�i'N1R�t #� 11D1I� tSlr9aM 1 1 . ,CtN�+IC�E�1l4�Q q�t�yi �i�39�kSP"" e , r_�