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Home My WebLink AboutWiring Permit - Correspondence - 0 FOSTER STREET 2/9/2016 Date.. o TOWN OF NORTH ANDOVER O � PERMIT FOR WIRING CHU9�� This certifies that ��'e Ins has permission to perform ,,,,, � ° a ..s-�E�.... wiring in the building .......................... at / p ........................North Andover,Mass. Fee Lic.Now ' ELECTRICAL INSPECTOR Check# 2(e i Offi ' 1 Use Only Commonwealth of Massachusetts � b , , Department f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C) 527 MR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ❑e City or Town of. NORTH ANDOVER To the Inspector of fires: By this application the undersign lives notice of)*or her intention to perform the electrical work described below. Location(Street&Number)— R4 Owner or Tenant Q�4dlieo �( � �U / Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service )-00 Amps 1�kV/ O ( olts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of roposed Electrical Work: f Completion of the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Cell: Trans Susp.(Paddle)Fans s Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency Lighting No. of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No.of Gas Burners No.of Detection andInitiating Devices No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons I.KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters signs Ballasts No.of Devices or Equivalent No.H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of 19lectrital Work: OC) (When required by municipal policy.) Work to Start: /Gj 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 permit issuing office. CHECK ONE: INSURANCE [ V BOND ❑ OTHER ❑ (Specify:) I certify,under th ain andpenalties. f perjury,that the information on this placation is true and complete. )) FIRM NA r LIC.NO.: /% Licensee: Signatu _ LIC.NO.: 5 d�4G/3 (If applicab e,enter "exeinpt"tot a license number line.) Bus.Tel.No.: . 6 Address: 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 PEtZMIT FEE: �$' 6 Signature Telephone No. The Commonwealth of Massachusetts Department of IndustrialAceidents 1 Congress Street,Suite 100 �< Boston,MA 02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAIITTING AUTHORITY- Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address: City/State/Zip- Phone#: Are you an employer?Check the appropriate box: Type of project(required): Lj�I am.a.employer with_:_employees(fall and/or part-time).* 7. ❑New construction 2,Q I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp"insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 electrical repairs or additions proprietors with no employees. I i F1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c, 14.❑Other 152,§1(4),and we have no,employees.[No workers'comp,insurance required.] *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 state whether or not those entities have ors have employees,they must provid employees. If the sub-contract e their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the worker compensation policy declaration page(showing the policy number and expiration date). Failure to secure c erage •equired under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year' priso nt,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 lolator. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veri cation. I to here rti re pains a enalties of perjury tliat the infor-rnation provided abov is and correct. i na e: / Date: P e#: 7 Official use only. o not write in this area,to be completed by city or town official, City or Town: PermitlLicense# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: