HomeMy WebLinkAboutWiring Permit - Permits #12469 - 150 FLAGSHIP DRIVE 6/24/2013 Date
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° PERMIT FOR WIRIN
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����.•��� ELECTRICAL INSPECTOR ze
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Commonwealth of Massachusetts Official Use Only
1
Permit No.
F Department of Fire Services
Occupancy and Fee Checked/
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00
(PLEASE PPJWTININK OR TYPE ALLMFORIWTION) 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)
Telephone No.
Owner or Tenant V
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
ilding e,�A )
Purpose of Bu Utility Authorization No.
Existing Service Amps Volts OverheadF] Undgrd[j No.of Meters
New Service Amps Volts Overhead❑ Uudgrd ❑ No.of Meters
Number of Feeders and Ampacity 7
Location and Nature of Proposed Electrical Work:
Completion of the followingtable may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminalre Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above o In- No.of Emergency Lighting
grnd. grnd.u 0 Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones
Na.of Switches No.of Gas Burners No.of Detection and
Total Initiating Devices
No.of Ranges No.of Air Cond. No.of Alerting Devices
Tons
HeatPump I.N!mhu 119M KW No.of Self-Contained
No. of Waste Disposers Totals: Detection/Alerting Devices
Munic, z-
lp,tP, n other
No. of Dishwashers Space/Area Heating IOW Local❑El Connection
No. of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No. of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts . No.of Devices orEquivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent-
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
" L
Work to Start: ', '1�4\, inspections to be requested in accordance with MEC Rule 10,and upon completion.
—L�� ��I: Unless waived by the owner,no permit for the performance of electrical work may issue unless
INSURANCE C VE
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 R BOND F1 OTHER El (Specify:)
I FcIRMNAME:erfify, under thepains andpenallies ofpqijwy,that he information on this application is true and coin,plete,
LIC.No. 2
7),
"l) tk LTC.NO.:_'
Licensee: Signature 1)'), ............ J—
(Yapplicable,enter exetnpt"in the license number e.) Bus.Tel.No. 7
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Address: Alt.Tel.NO.t-u c),
*Per M.G.L c, 147,s.57-61,s6curity 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)F1 owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE.-
The Commonwealth of Massachusetts
Department oflndustriqlAccWnts
Office of Investigations
600 Washington Street
Boston,HA 02111
vwW-mass.gov1d1a
Workers, Compensation Insurance Affidavit: Builders/ContractorR/Ele,etricians/Plumbers
Applicant Information Please Print Legibly
NaInc)(Business/OrganizatiorAndividual):
Address: Z),5"'14/1,1
rk
Phony
Are you an employer?Check the appropriate box: Type of project(required):
I�'[fj am a employer with 4. F1 I am a general contractor and 1 6. E]Now construction
employees(fall and/or part-time).* have hired the sub-contractors rol 7. F1 Remodeling
211 lamasolop* -orletor or partner- listed on the attached shoot.
ship and'havo no employees These sub-contractors have 8. F]Demolition
working forme in capacity. workers' comp.insurance. . I
or 9. F1 Building addition
[No work-cis' comp.insurance 5. F1 We,are a corporation and its 10 repairs or additions
required.] officers have exercised their
3111 am a homeowner,doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions
myself. [No workers'comp, c. 152,§1(4),and we have no 12.Q Roofrepairs
insurance required.] employees.[No workers' 13.[--]Other
comp,insurance required.)
xAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they ac doing all work and then hire outside contractors must submit a now affidavit indicating such,
tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that isprovifflng workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
Policy 0 or Self ins.Lic. Expiration.Date:
—
Job 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 ofMGL c. 152 can lead to the imposition of criminal penalties o'f a
fine up to$1,500.00 and/or one.-year imprisonment,as wollas 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1do1;erehj'eez,119undq e a1ns,,andpena1t1es,9fpeiYury that the information provided above is true and coriect.
Sign re: Oill'11/�,
Date:
Phone
Official use only. Do not write in this area,to he completer)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
I Contact Person: Phone 9:
•
Ct?NIMONWEALTH OF MASSACHl1SETTS
I • ,
BOAI�p OF i
ELEC�RJ c I"ANS
ISSUES THE FOLLOWING LICENSE #
AS A REG JOURNEYMAN ELECTRICIAN"
DEREK DEMATTEO Z
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10 PONDEROSA DR
H.uDSON NH 03051-5404
2517JR 67' 31/1.6 . > 72506