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Home My WebLink AboutWiring Permit - Permits #12572-1 - 287 FOREST STREET 8/10/2015 i Date d........ ........... a,.?:' : :'• °o� TOWN OF NORTH ANDOVER * # PERMIT FOR WIRING n '88ACHUB��4 _ This certifies that .......... . . .. ........................................... has permission to perform ,•,,,� �. k • .................................... wiring in the buildingof .... at t _ ......••�••• ,Nort,h ndover,Mass. Fee Lic.No ELECTRICAL INSPECTOR Check# PS t Official Use Only Permit NO. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank) APPLICATION FOR Pr ERMIT TQ PERFORM ELECTRICAL WORK All work to be performed in ac&rdence with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR kYPE AL INFORMATION)` Date: City or Town of: hbyk kdv-r;,- 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) o? Owner or Tenant ar v\o fy 10 a u,—I A 4 SSG V- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No r01 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ UndgrdF-1 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 ofthe following table may be waived by the Inspector ofillires. No.of Recessed Luminaires No. of Ceil.-Sus .(Paddle)Fans No.of Total p Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above Ei In- EJ No.of Emergency L g ing g grnd. grtid. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS jNo.ofZones N—o. of Detection and No.of Switches No.of Gas Burners Tota Initiating Devices No.of Ranges No.of Air Cond. Tonsl No. of Alerting Devices eat Pump umber ITons .1.K.W...........I No.ofSelf-Contained No.of Waste Disposers Totals: ........... . ..... Detection/Alerting Devices L I I Municip�d No.of Dishwashers Space/Area Heating KW Lociii❑0 Connection EJ other r ecurity No.of Dryers Heating Appliances KW ecu No. Systems:* of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telec of DeviWnr,m,�: No. Hydromf!ssage Bathtub., No. of Motors Total HP No.of Devices or Equ va ent OTHER: Attach additional detail if desired, or as required by the Inspector of lVires. 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 R1 BOND [—] OTHER [:] (Specify:) I certify,under the pains and penalties of perjury,that the informal n an this application is true and complete. FIRM NAME: Village Electric Inc LIC. NO.:9163A Licensee: Anthony P, DelPapa Signature LIC.NO.:21861 E (If applicab applicable, "exempt"in the license number line.) Bus.Tel. No.!978-2564845 Address: PO Box 4044 Chelmsford, MA 01824 Alt.Tel.No.: 'Per M.G.L.c. 147, s. 57-6 1,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 [I owner's agep Owner/Agent Signature Telephone No. PERMIT FEE: $ Z "Sk X I,� U The Commonwealth of Massachusetts .' Department of IndustrialAccidents 1 Congress Street, Suite 100 .` .Boston,MA 02114 2017 v° www.mass,gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers. TO BE EIGED WI` EC TEL' PERMT TING AUTHORITY. Applicant Information Please Print Le 'bl �aTName, nsiness/Or• anizati (B g onffridividual): V Address: p Phone (� y-� I gpryy q., g City/Mate/Zip: Are you an employer?Checkth appropriatebox: 'Type of project(gquired): LE]I am.a.employer with � employees(full and/orpart-time).* 7. F1 New construction 2. I am a solo proprietor or partnership and have no employees working for me in 8. "Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition . 3..Q I am a homeowner doing all work myself.[h7o workers'comp.insurance required.]t 10 Building addition 4Q 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.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have erinployees and have workers'comp.insurance.1 6.Q We are a corporation and its of�cers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] "Army applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who subrriit•this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. rContractors 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,%ey rirust provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for niy employees.'Below is the policy andjob site information. Insurance an Comp y Name: t. . . ib a�qw� � ]xationD� '^� y ate: Policy#or Self ins.Lic.#. a p M , fob Site Address: �' � i City/State/Zip: Attach a copy of the woAKers'compelrsation'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 vertrica ro . X do hereby er the ains andperaalties of perjztry that the informationprovided bov is true and correct. Si nature: ` ' ate: Phone#: 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#: Imo I S FOLLOWING :I 1 ICIAN , VILLAGE ELECTRIC 4 r � rl ,4430 BOX 404 9 3 A 07 / 31 / 16 j 6 3 331, COMMONWEALTH OF MASSACHUSETTS e 2 3 # P ^ u BOARD OF [ LECTR I SSUES THE. L - I . LICENSE, ANTHONYAS A REG JOURNEYMAN ELECTRICIAN P DELPAPA, o Box 4044 � a OUTH CHELMSFO MA 01824 - o644 21861 E 07 / 3U16 27 -132 USET 1ORTS WA - 4END 4dNUMBER ig sex M 1D for 5 88 c: 2AtTHONYP. 125 PROCTOR AD CHELMSFORD,MA 01824 4453 fS DO 03.2o-2014 Rev 0745.2009 ':, , ^ ' � Date Town of North Andover Your permit has been sent back to you for the followingreasons: 1\ Check amount incorrect 3) Nn copy of current license 3 A k A \ |nsU[�DcaBindernotoDU|� VreXpi[ed ^�L~�� `\ m�� ^r�� ^^-1 ' --------' � U 4\ No Workers'Compensation Insurance Affadaxit For Please call with any questions y78-688'gS45..Fax 978'GX8-9S42 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover VVebaite under Building Department. Mailing Address: 1GOO Osgood Street, Building 2[L Suite 2O3S, North Andover, K4A01845