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Home My WebLink AboutWiring Permit - Permits #12880-1 - 650 FOREST STREET 11/23/2015 i ........... i NORTh TOWN OF NORTH ANDOVER PERMIT FOR WIRING B�CHUg� �s This certifies that a (7 �l CA ........... i has permission to perform ... l t��-f� k V� .:..�� ,3 e f� ..... ..... ........... wiring in the building of... ro: : .................................................................................. t � at ... L I . ......... ..............North Andover,Mass. Fee. Lic.Na ...................................... ELECTRICAL INSPECTOR Check# Commonwealth of Massachusetts Official Use Only I Department of File 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(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:_ ` /12,31/rf City or Town of: 4A,,, ._155,c4xo 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) (,; SCE Owner or Tenant nr._t Avt'ctca r�yr Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Buildin Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowin table may be waived by the Ins ector o Wires. No. of Recessed Luminaires No. of Ceil:Susp.(Paddle)Fans o.of Total ! Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool rnd. ❑ -rnd. ❑ o•o BatteryUnits cy ig Ong 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 No.of Alerting Devices No. of Waste Disposers eat Pump Number Tons KW No.oSelf-Contained Totals: ............ Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other M ms No. of Dryers Heating Appliances KWSecurity te : No.of Devices or Equivalent rN •oi water KW o.of No.o Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail ifdesired, 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 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 ❑X BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete FIRM NAME: NITS Electrical Contracting LLC LIC.NO.: A20279 Licensee: Michael T.Sarat Signature -� r�, iiZ` LIC. NO.: B10061 (If applicable, enter "exempt"in the license number line) Bus.Tel.No.:781-706-0883 Address: 31 Vincent Street,Saugus,MA 01906 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 PERMIT FEE: $ Signature Telephone No. I he Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): WS Electrical Contracting LLC Address: 31 Vincent Street, Saugus NIA 01906 Phone#: 781-706-0883 Are you an employer?Check the appropriate box: Type of project(required): 1.Z I am a employer with -Z 4. R I am a general contractor and 1 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. F.J I 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. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.: 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3. F-1 I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no 13. Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#I 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 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. Below is the policy and job site information. Insurance Company Name: Utica National Insurance Group Policy#or Self-ins.Lic.#: 4665367 Expiration Date: 07/16/2016 Job Site Address: 650 Al-Y S 51 City/State/Zip:M,, 4,c/ 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 form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: ],Sr Phone#: 781-706-0883 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSETTS BOAR.:Q .t ELEI�TR 1 G(A:: 1 SSUES THE :FOLLOWING L.!CEASE A5 A REfSTERED MASTER E;LECTRIGIAN Icc �Q M1GHAEL T SARAT , 31 V I NC, ST �. �'Z l IU SAUGUS ;; MA 01906 162$ iJ 2027g 07/31/16 27,744 J