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Home My WebLink AboutWiring Permit - Permits #11807 - 86 FOREST STREET 8/21/2013 Date.... yOH7y 4ti ?: : .'• °o� TOWN OF NORTH ANDOVER m PERMIT FOR WIRING CHU This certifies that " :., ......... E has permission to perform ....' " ' � �� G � wiring in the building of......... - ' at .� orth Andover Mass. Fee = Lic No .. .''�`` ��.'�� ECTRICAL INSPECTOR Check# The Commonwealth of Massachusetts Department oflndustrklAccid is Office of Investigations 600 Washington Street Boston,MA 02111 vwwmass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele,etricians/Pltimb erg Applicant Information Please Print Legibly Name,(Business/Organizationlfndividual): R cr-,C-0 Address: s k)i,e City/State/Zip. Phone#: re you an employer?Check the appropriate box. Typo of project(required): I I am a employer with 4. F1 I urn a general contractor and I 6. E]Now construction employees(fall and/or part-time).* have hired the sub-contractors7. E]Remodeling 2.0 1 am a solo proprietor orpartner- listed on the attached shoot.� ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9 I wilding addition [No workers'comp,insurance 5. D We are a corporation and its . [])Bu required.] officers have exercised their 10.F1 Electrical repairs or additions 3.El I am a homeowner doing all work right of exemption per MGL 11.n Plumbing repairs or additions myself. [No wor1cers'comp, c. 152,§1(4),and we have no 12.Q Roofrepairs insurance required.]T employees.[No workers' Un Other comp.insurance required.] J May applicant that checks box#f must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is thepolley and job site information. Insurance Company Name:. C.'.r,)cr,\ C", Policy#or Self ins.Lie, Expiration Date: C)(:-. kU k Sob Site Address:— -,City/state/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can load 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 iip to$250.0 0 a day against the violator. Do advised that a.copy of this statement may be forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. 1 do hereby cerfify under the p ains an dp en allies ofp eiyuiy that the information provided above is true anti correct Sim re: Date: 3, Phone it: Official use only, Do not iprite in this area,to he completed by cl(V or town official City or Town: Permit/License N Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rcv. im] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 MR12,00 (PLEASE PNNTININK OR TYPE ALL INFORMATION) Date: e City or Town of: NORTH ANDOVEi 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)_.. k/-Cs Owner or Tenant �M C-e- Telephone No. Owner's Address 1�A Is this permit in conjunction with a building permit? Yes F11 No ❑ (Check Appropriate Box) Purpose of Building ,3,,r\<A0 vx-c-, kl Utility Authorization No. 4j Existing Service_ Amps Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps Volts Overhead n UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:. . rn o 'V' Completion of the followingtable may be ivalved by the Inspector of Wires. (N) -Susp.(Paddle)Fans No.o Total No.of Recessed Luminaires No.of Cell. Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA Above Ei In- N-0-70—umergency Lighting ❑ No.of Luminaires Swimming Pool Units 2rnd. ❑ grnd. ❑ Battery T ... No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones No.of Switches No. of Gas Burners No. of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices I No. of Waste Disposers Heat Pump I Number I Tons IKW No.of Self-Contained Totals: I...........................I.........................I................. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local D Munlc'PP' n Other Connection No.of Dryers Heating Appliances KW 'Security Systems:* No.of—W No.of Devices or Equivalent Heaters No.of No.of Data Wiring: eaters '�W signs Ballasts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent .OTHER: I � Attach additional detail if desired,or as required by the Inspector of Wires. ,Estimated Value of Electrical Work: -;,�!SX.)10 a (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 [n, BOND F] OTHER [I (Specify:) -1 FIR cerfifyMNA, unMderE-tali epain (ins dpen altiesk ofp e�ijiny,that the information on this applicationLIC.NO is true and complete, C- --0.: A Licensee: Signature LTC.NO.: 3�0 C (If applicable,enter "exempt' in the license number line.) Bus.Tel.No. 13?) e Address: ik.-A - &-ey �sAL>-Q. 'v�Z� v,(N Alt.Tel.No.: *Per M.G.Lc. 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)0 owner [I owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ p ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shait.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends;for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule R—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 B#r<f Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature, Date: FINAL,INSPECTION: Pass 0 Failed Re.;Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: EB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com