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Home My WebLink AboutWiring Permit - Permits #12926-1 - 706 FOSTER STREET 12/3/2015 I Date.�. ............... I NORT/� `TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,gBACHUS� P � . I This certifies that ..�............. ................ has permission to perform .......... ........ .• wiring in the building o ..... ......................... ..... .. K- 'e 1. ,North Andover,Mass. Y at .:A . ........................... Fee........................:....Lic o :. ......................ELECTRICAL INSPECTOR Check# _ _-------- e Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Chocked BOARD OF FIRE PREVENTION REGULATIONS IROV- 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in(PLEASE PNNT IN JATK OR TYPBA LL accINFORMTION) Dordance with the Massachusetts Electatriecal Code(MEC),3 527 CMR 12.00 LL 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) 7 7-(,�, Owner or Tenant '41 Telephone Noko Owner's Address Is this permit in'conj unction with a building permit? ❑ Yes F1 No El (Check Appropriate Box) Pill-pose of Building Utility Authorization No. 31 Existing 71�Amps Volts Overhead-n-, UndgrdE] No.of Meters New Service Amps Volts OverheadF1 Undgrd n No.of Meters J�1.',/, I/ A Number of Feeders and Amp acity Location and Nature of Proposed Electrical Work: Completion of the, table may be waived by the Inspector of Wires. f. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA Above o In- N-07-01T,mergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. El Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo. of Zones No. of Detection and No. of Switches No.of Gas Burners Initiating Devices No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices al HeatPump ICW No.of Self-Contained No. of Waste Disposers Totals: Detection/Alerting Devices Municipal n Other No. of Dishwashers Space/Area Heating KW Local Connection y Systems:* No. of Dryers Heating Appliances KW Securit No.of Devices.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: I No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 worlc 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 [I BONDE] OTHER [I (Specify:) I certify, under thepains andpenallies,qj-�pqrjury,11 �the information on this application is true and complete, �ai FIRM NAME: 's cr, MC.NO (r�) V Licensee: Asi� 8jignature LIC.NO.: umber N 0— e,enter ex Pt"I he licenfe n I L -�') & C') Alt.Tel.No.: (If applicab Bus.Tel.No.: "'12 Address: *Per M.G.-L u. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVE R: 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)[I owner [_1 owner's agent. Owner/Agent Signature Telephone No. PP)MITFEE. $ 4 � The Commonwealth ofMossaehusetts f Department of IndustrialAceldents 1 Congress Street, Suite 100 ti Boston,HA 02114-2017 wwwanass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILE WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl u. Nalne(Business/Organization/fndividual): i�„, �� -. , r ,t•�� Address: .... n Ivy, , ) I'll' ' µ. , e V, M , :� C 1, City/State/Zip: �" , Phone#� Are you an employer?Check the appropriate box: Type of project(required): 2-1.� -1 am a employer with employees(full and/or part-time).* '7. Q New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. [1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. ltr'ical repairs or additions proprietors with no employees. 0 1/—.Q Plumbing repairs or additions 5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs airs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other oyees.[No workers'comp.insurance required.]I52,§1(4),and we have no empl *Any applicant that checks box 41 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 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.' Beloip is thepolicy anal job site info]-mation.Insurance Company Name. Policy#or Self-ins,Lic.# Expiration Date. 12,cea Job Site Address: ) h". '" City/State/Zip: Attach a copy of the worke s' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. h I do hereby certify render„tir' pains andpenalties of peijwy that the informationprovided above is true and correct. .. e. r "' YPhone#: i"nature,: < Date: ✓� ." °`» / . Official use only. Do not sprite 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#: :..COMMOiV1N ALTH O 'MASS C,"HUSETTS ® ® s BOARD ELE'CtR1 C'I ANS ISSUES THE FOLLOWING LLCNS6 AS A REG i STERE'D MASTER. ELECTR I C LAN I� , F .lQSEPH.G ELKHOURY: ? 27 CHARGES...ST Z r 4 � NORTH 'ANDOUER MA 01845-16bk ��