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Home My WebLink AboutWiring Permit - Permits #12810-1 - 150 FLAGSHIP DRIVE 10/28/2015 . i Date.. :. :. L .............. O�Noprhgtic TOWN OF NORTH ANDOVER i p PERMIT FOR WIRING CHUSE R f This ce es that,.......... s CC was permission to perform�, .:'..CCCC .�`...�` �` ` 'GV.......°.. .� ram. �a wiringin the buildingof......... ............................................................... ..... � � IV� North Andover Mass. at ... � t..s.. f .... .. ......................... Fee..... .......................Lic. No. . Ldl .................................................................................... ELECTRICAL INSPECTOR Check# Commonwealth of Majdac4u-jeltj Official Use Only Permit No. 2apartment ol3ire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: 16-.2 City or Town of: X,1, 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) Owner or Tenant '�-/ Telephone No. � Owner's Address Is this permit in conjunction with a building permit? Yes P— No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead 0 Undgrd EJ No.of Meters New Service Amps Volts Overhead F-1 Undgrd F No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /P.I i6c aLAJ I JI"t Completion of the.following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of TotalTransformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA ,1 n mg ot Emergency Light dN No.of Luminaires Swimming Pogrnd 'r- 11 nd. Battery Units cam_No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo.of Zones No of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Dis eat Pump I Number ITons 1KW No.of Self-Contained p osers Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local F-1 Conne ctip Mun i ical E] Other on Security Systems:* No.of Dryers Heating Appliances KW No.of Levices or Equivalent No.of Water No.of No.of Data Wiring: 15- Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: )5- No.of Devices or Equivalent IOTHER: Attach additional detail if desired,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 [I BOND F-1 OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: DUCOM Electric, Inc. LIC.NO.: 12652A Licensee: Richard C. Dugas Signature LIC.NO.: 26968E (If applicab$enter "exemp i the license number line.) Bus.Tel.No.:978-6 4 0-044 Address: .0. Boxt 928 No. Reading, MA 01864 Alt.Tel.No.: 0 *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)0 owner F-1 owner's egt Owner/Agent $ aM Signature Telephone No. PERMIT FEE: C ;: � �..; �.. The Commonwealth of Massachusetts Department of IndustrialAccidents " I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNQTTING AUTHORITY. Applicant Information Please Print Letsibly Name (Business/Organization/Individual): Q X ally J'C Address: 11./ 5AJ9),J 56C-C-bn S4 City/State/Zip: Phone##: q -� Are you an employer?Check the appropriate box: Type of project(1 equired): l.D],1-atn a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am'a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.E]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 employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL G. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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. lam an employer that is providing workers'compensation insurance for•my employees.'Beloiv is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie..#: Expiration Date: Job Site Address: /" �' r City/State/Zip: ttach a copy of the workers' compensation p licy declaration page(sl(owing 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi e•t�1� enalties ofperjury that the infornratioraprovided above is true and correct Si nature: Date: Aa Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit[License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 10/28/12015 11:35AR1 FAX 19786401')220+ DUCOM ELECTRIC 0002,'0i102 1 .C}MMCNWGTFI OF MIAHt@T� s ` �4Bt�ARD C>F . 1 SS11�S wTNE �OLL04�lfi1�„ ttt 7 AS; R ,RAG;:1Ol1RNEYMAN ELECTR I G,I,Q`N..::' jR I CH a�tD 3 a s �`VVII "I�dl `fiH' REAtl.i�l�tY€;MA Cl;Bb�+ C :MNIbNVII ALTH t0F >UTA-0. USET A%S S a �� l,S`SUE5;;�'I1E$FOLLOW!"�1G L`IC�NSE AS A',;� fr , CrtI A 5T TR£Il M . r ,❑ hhY j r � �- n �! 1 13,�� yi r 1 s 1p VJtlVail R C 11YL � I'irt �}r RI CFIARRj f13TJA r , �6 5953 �b5 Lo7/31%. A '