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Home My WebLink AboutWiring Permit - Permits #11555 - 75 FOREST STREET 5/3/2013 Date.. 0 ........ .. ....... � ........... CF t4oR TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHUS� i � 9 This certifies that .,. 9 { ........ has permission to perform .................. .. r f.:- t ................................. wiring in the building of, ,a """' at • s �.......� �..�..... �� r _ .................. ...North M Fee ° dover,Mass. ......................Lic.No � Check# " ELECTRICAL INSPECTOR r i Commonwealth ®f Massachusetts Official Use Only 0.Permit N Department of Fire Services Occupancy and Fee Chocked BOARD OF FIRE PREVENTION REGULATIONS [Rev.im] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PMTINJNK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVE,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) 7S, k 1'e S'i, /S Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes FRI No ❑ (Check Appropriate Box) Purpose of Building e � i / Utility Authorization No. Existing Service Amps Volts Overhead [] Undgrd[] No.of Meters New Service Amps Volts OverheadD Undgrd n No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: C �','e, ON Completion of the following table inay be waived by the Inspector of Wires, No.of Recessed Luminaires Z.. No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In- F1 No—.—OTEmergency Lighting grnd. grnd. Batter v Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No.of Gas]Burners Initiating Devices No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices al Heat Pump Tons I KW No.of Self-Contained No.of Waste Disposers Totals: IAMM4�r].........................F..................... Detection/Alerting Devices Municipal F] Other No.of Dishwashers Space/Area Heating KW Local❑F] Connection ur it y of Syste No. of Dryers Heating Appliances KW SecN o. Devices or Eguivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equiva ent Wirin : No.Hydromassage Bathtubs No.of Motors Total]UP Telecommunications No.of Devices or Eouivaglent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. `Estimated Value of Electrical Work: L-k �C' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC 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. cBEci-,, ONE: :lNsu-PA-NcE F1 BOND El OTHER El (Specify:) I certify, it n(lei,the e p ains an dp en allies ofp eijury,that the inforni ation on this application is true and complete. FIRM NAME: . .c rC)j. Licensee: Signature LTC.NO.: x). inp e nNo..:: ffapplicabie—,enter "exet"in the licensum ber line.) Bus.Tel.No.f."::� Address: i L-,� n R o(I Alt.Tel.No.: T1Y *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)[I owner P owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ❑ 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 shall 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 8—Permit/Date Closed: **Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass ? Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Sx- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 W www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): e C, (L Address: 41 City/State/Zip: , Phone#: - you an employer?Check appropriate box: Type of project(required): 1, A, T a employer with 4. n I am a general contractor and 1 6. FJ Now construction �r Y1, employees(full and/or have hired the sub-contractors 7. F1 Remodeling 2.El I am a sole proprietor or partner- listed on the attached sheet.$ ship and'have no employees These sub-contractors have 8. FJ Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp.insurance 5. F1 We are a corporation and its 9. E]Building addition 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 workers' comp. c. 152,§1(4),and we have no ME],Roof repairs insurance required.]t employees. [No workers' 1311 other comp.insurance required.]— *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie 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. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and'job site information. Insurance Company Name:. Policy#or Self-ins.Lie.9: Expiration Date: 1 'ity S Job Site Address: -�y_/W?Late/tip: 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 MOL o. 152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/or onc=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. I h do ereby certoy' r4ligXalns a enalties ofpeijuiy that the informationprovided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 0 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 N: