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Home My WebLink AboutWiring Permit - Permits #12500 - 202 FOSTER STREET 7/7/2014 f . i Date.................... i �.�.•:`��. :'•ti°o� TOWN OF NORTH ANDOVER a PERMIT FOR WIRING HU9� I This certifies.that pa ......... .............................. ..... ........ has permission to perform ,....��,s.� ',:...:... �a?;.:�..�; � �'�..�.�°�... I � wiring in the building of........... .°: .s. .`.................................... .. ........................ ....... at ��.. ... ........... :. ... ..... ............,,North Andover,Mass. Fee..o.. ....:. ..........Lie. No. . : :: ....................... ,v.,.b.. . ..... LECTRICAL INSPECTOR t � -- � Check# _ (fotninoniveaftli of ka.maeltudeth u _ official Use Only� C; c� Permit.No, 2epartinent o f Sire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (le<#vc blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts l lecu'ical Code(MEC),527 CMR 12.00 (PLEAEF, PRINT IN INK OR TYPE,ALL INFORMATION) Date: 7/1/14 City or Town of: North) Andover To the btspector oj'Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 202 Foster Owner or Tenant Mrs. Cain Telephone No. Owner's Address Si,me Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Dwelling Utility Authorization No. Existing Service 200 Amps / Volts Overlicad ® Undgrd❑ No.of Meters 'I New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replace wire tinder 3 season torch real-wall hang 2 2nd fl hall lights, replace GFC l outlet in kitchen, replace GFC:1 on rear porch Completion of the 1611owin g table mars he ivaived by the Inspector o1'Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers I{VA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o !Emergency ,ig i ing rnd. rud. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones. No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pu►up Number 'Pons KW No.of Self-Contained Totals: .........................................._.... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW 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: I-Icaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bath H tubs No.of Motors Total HP Telecommunications Wii in No.of Devices or Equivalent OTHER: 300.00 � Q3 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work; (When required by municipal policy.) ready for inspection Work to Start: 6/28/14, Tnspections 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 tmless 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 ant/penalties of perjury,that the infi)rtnadon on this applicatio,,pis t ue and complete. FIRM NAME: Bass River Service s ,i ,,tlC.NO.: A 11520 ;tan �C_NO.: I..,iceusee: Eric Chisl1nlfn Signatur ;„� ,� I' " ". (If applicable,enter"exempt"in the license nuniber line.) Bus.Tel.No.:9 78-578-2098 Address: 105 Odell Ave, Beverly Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security world 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,T hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. P RmiT TT.TF,Et $ The Commonwealth of Massachusetts a"s 1 Department of Trrdustrial,Accidents Office of'Tiavestiatlorrs .1 Congress Street,Suite.100 ❑4 / Boston,MA 021.14-2017 ' •t:::.i``- wrvw.rrtass.gov/dca Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Tiusiuess/C:h•ganization/bzdividuul): Bass river Services Address:105 Odell Ave City/State/Zip:Beverly, MA 01915 Phone#:978-578-2098 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ i am a employer with 4. n i am a general contractor and 1 employees (frill fund/orpart-tune). have lured the sub-contractors fi. ❑New construction 2.M I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have & EJ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance. t ) [�Building addition ❑ We are a corporation required.] 5. poration and its 10.n Electrical repairs or additions I 3.❑ I am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself. [No workers' comp. right ofexenption per MGL 12.❑Roof repairs insurance required.] f c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Airy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit t his affidavit indicatiag they are doing all work and then hire outside contactors must submit a new athdavit indicating such, tContractors that check phis box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If'titc sub-contractors have employees,they must provide their workers'comp.policy number. 1 arrr on employer'that is providing rvorlcer,s'compensation insurance for my employees. Below is the policy and job site information. insurance Company Name: Policy#or Self-ins, Lic.#: Expiration Date: Job Site Address: All Jobs — ......__. City/State/Zip:N.Andover 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 firm 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 cover f' verif4ion. 7 do hereby eertyji under the pairs and per ro ties /y' Jury that the in rrnation provided above is true and correct. 7/1/14 Si nature '3, �'" � " o � �" -- Date: Phone._#__9785782098..-..-..-._ -- — 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#: