HomeMy WebLinkAboutWiring Permit - Permits #13082 - 46 FOSTER STREET 1/26/2015 Date............ .... ...........
�?a NORrMgtiooL TOWN OP NORTH ANDOVER
° PERMIT FOR WIRING
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This certifies that ......... .... .. ....... .....................
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has permission to perform
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wiring in the building of. ....... .y...'.. ......
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at: ` i ` h Andover,Mass.
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o Lic. No :.��.€ x �
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ELECTRICAL INSPECTOR
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Pcutlil No.
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Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/99) (!cave blank)
APPLICATION FOR PERMIT. TO PERFORM ELECTRICAL WORK
All work to be perfomed in accordance With the lrlassachusetts Electrical Code � �. ( C7,SZ7 t.lR IZDO
(.PLEASE PRINT IN INK OR 7- 7TE:ILL I YFORA1.4 TIOY) Date: ; /
Cite or Town, o.C:... ; w To Me itsPeclor of Wit-es:
By•this'application[lie undersigned gives not.cc-of lus.or her intention to perform the electrical work described below,
Location Street& Nurubcr r',
Owner or Tenant � , ..: . , . Telephone No.
<°�
Owner's Address I
Is this permit in conjunction with a buildin; permit' ves No ❑ (Cllccl:Appraprintc Box) .
T"urpose of Building OP . 4 Utility Au(horiT,alion No.
Existing Scrvice Amps o I L s Overhead Undgrd ❑• No. 0r'N1v.ters
New SCMICC Amps / Vofts Overhead❑ Utldgrd ❑ No. or Meters
Number of Feedcr-s and Ampncity
of Proposed Electrical Work:. .
Location and Nature
Completion o(•tlne following sable map br uaivcd by the sus actor o[Wires. r
No'. of Recessed Fixtures No. of Ceil:Susp. (Paddle)Falls No. of Total
Transformers KVA
No.'of i,ighting Outlets No. of Hot Tubs Generators K!'A
Above ln- o. a Mergence ,rg tting
-Na. of ,inh-tingFrstures SSYlntning Paul rnd. rnd, ❑
❑ $atter-t' Units
No, of Receptacle Outlets 4 �. No. of Oil Burners FIRE ALARMS ?Vo.ofZones
No, o[Switches No.of Detection and No. of Gas Burners Initiating Devices
No. of Ranges No- of Air Cond. Tans No. or Alerting Devices
�o, of Waste Disposers HcatPutnp Number Tans KW No. of elf-Contained
p Totals: Detectiou/Alerting Devices
No. of DBI nvashers Space/Aren Heating k-W Local ❑ Municipal ❑ Other
Connection
No. of Dn�ers Heating Appliances It1V Security Systems:
Na. of Devices or E uiva•lent
Na, of`1 ater KW Nq. of tya.of Data Wiring:
Heaters Signs Ballasts Na. or Devices or Equivalent
No. EydE�ornassage Bathtubs No. of Motors Total HP I'ciccomrfDev CeS or
�1'iriug:
No:oC.Devices or E en
Ol THER: . .
Anacn additional detail if desired, or as required by the Inspector of Wires.
IINSUR-41NCE COVERAGE: Unless vaivcd by the cm-mer,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation"covetagc'or its substantial equivalent. TI)
undersigned certifies that such covcra; is in force, and has exiiibitcd proof of snroc to the permit issuing nf6ce.
.CHE,CK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
(Expiration ate)
Estimated Value of Electrical Work: (When required by municipal policy-)
Work to Start: Ae,0 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, an der Me p-ains and penaltiesrrof ppc urn, d:crt the zrlfornlvtiorr on this application is true and cornplef� -
fIIZl1[ LTC.NO.:�� ' c�?.f_ '
Licensee
Al",I gyp+ Signature ' ... _ LTC NO..�
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(� I P P nse mcorber.line) I3us.Tel. IN.o r , "
Address- ✓
! a t Itcable, cuter "r_rcm t 'to the lice
� A- h, � ��.,. �,�,, Alt.Tel.Na.: '
OW R A NER'S IN.SUACE yANER: I am aware tl}at the Licensee does not/rava the liability insurance caverage normally
required by Iaw. By my signaturc belong,I hereby naive this rcgniren' irt_ I am the (cheek onc) [] owner ❑ owner's agent.
Signature __ 1•clephoneNo. LPLIZilfZ.T.FLL: S
The Commonwealth of Massachusetts02 —'
Department of IndustrialAccid.ents
0riee of Investigadons
I Congress Strret,Suite 100
Boston,MA 02114-2017
www mass gov/dia
Workers'Compensation Insurance Affidavit:Bullders/Contractors/Electricians/Plumbers
Aonlicant Information Please Print Ugibly
Name(Buei=&organizwmqudivi&w): I'
"
Address:
Ci /state/Zi ✓° c.-, / Phone#
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general eowractor and I 6. []New construction
epiployoes(full andlarpurt-time).* have fired the sub-cowrec ors
2.M I am a sole proprietor or partner• tided on the attached sheet 7. ❑Remodoling
Vs*and have no employees These Rib-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp.insurance= 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10." lectrical repairs or additions
3.❑ I am a homeowner doing all work --officers have awcised their 11.0 Plumbing repairs or additions
myself,[No ems' gip, d&-of Mtemption per MOL 12.0 Roof repairs
insurance ce required.]t c.152,41(4),and we have no
employees.(No ' 13.0 Other
*AnY 4*l�t Wet obaci:t bunt fli nand akin fill oat the nation bdow ahaa Wear wo let I ampo ssfi n poUcy leftm don.
t Homwwnere who mdmk Wit etridwk iodicaWl Wwy we dobaa aU wort sad Wan biro ouM&oanoaaI no mbmit a sew affidavit iodicaM such.
=Caatraotnn dw dw*Wit boat 00 egadrod at additional abed rIn We orme dWe arb•aonbown and state wbodw or not Wore a W in cave
empio)en. If the sub-cookedoer bare ampioyeet,Way rand povide Weir waken'camp.policy ammbax.
a"art wmploytr tka!is prorldbtp ttwrkers'crnrparsetfon ftw me for cry eat bytes. Bdow b Me policy and Job site
Wonnadom
Insurance Company Name: —
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: N)Yitypstste/Zip�
Attach a copy of the workers'compensation policy declaration page(showing the policy anmber and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can Ind to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisommnt,as well as civil penalties in tie 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 may be forwarded to the Office of
Investigations of the DIA for huanance coverage verification.
,arc
t do kaweby.e¢ro and r Ikepahn and pauMa of perjury aYd Ike IRformgdon proc'ldd i ve is tare and correct
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Official use only. Do not write In this area,go be a om#ete+d by city or town oftkial.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector S.Plumbing Inspector
6.Other
'Contact Person: Phone#:
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