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Home My WebLink AboutWiring Permit - Permits #12630 - 8/21/2014 {i Date....., � p10RT/y OF �ti TOWN OF NORTH ANDOVER A�?° 1 �� '• 00 O . L ;� • ; PERMIT FOR WIRING ,g8gcwuss� P u f This certifies that N . .L t5 has permission to perform ` p .....:, wiring in the building of.,., . ......... ...................................... at ....s �..... F....i..: 9....... �. ... rrl�North Andover,Mass, Fee Lic.No. ELECTRICAL INSPECTOR Check# `t `' Y Commonwealth of Massachusetts Official Use Only D F epartment of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /,/a,)l I Z City or Town of: NORTH ANDOVER 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)❑ Tv, 6,v 0 �- Owner or Tenant Telephone No. ;q Owner's Address Is this permit in conjunction with a building permit? Yes [I No F] (Check Appropriate 13ox) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd[1 No.of Meters New Service Amps Volts OverheadF] Undgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: &+ncl IIem)Ir-e 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 Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In No—.—ofT mergency Lighting Rrnd. grnd. ❑ Battery Units No.'of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. Of G28 Burners No. of Detection and Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Reatrump Number Tons..........J.KW........... No. of Self-Contained Totals Detection/Alertjng Devices -1 No.of Dishwashers Space/Area Heating KW Local El Municipal Connectio n Other n 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 or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail f(desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /4�?V (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: iNsu-PANcE F] BOND D OTHER F] (Specify:) I certiryFIRM , under thepains and penalties ofpetjuiy,that the information on this application is true and complete. t NAME: 61, LIC.NO Licensee: Signature LIC.NO.: (1fapplicable,enter "exempt"in the license number4ine.) Tel. Address: 19 Alt.Tel.NO.; *PcrM.G.Lc. 147,s.57-61,security workic4uireg Department of Public 9afety"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 []owner's agent. Owner/Agent Signature Telephone No. $ t2-6-0- 1 The Commonwealth of Massachusetts Department of IndustriqlAceikhts Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): 7 Address: � :� ,, .._. °.:� m..- � City/State/Zip: o; '' r241("1rl/ Phone#: , �r ' / r' Are you an employer?Check the appropriate box: Type of project(required): .1.0 1 am a employer with_ 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10. )Electrical repairs or additions required.] officers have exercised their 3.111 am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12,[J Roof repairs insurance required.] 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. Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. y Insurance Company Name:. p /0 Policy 4 or Self ins.Lie. 1,i)(1P gym...L2 3 ✓ /f . Expiration Date: Job Site Address, ` � ' ,� /i 1 �6. Ci /Statc/Zi _L 1 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 c. 152 can lead 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 up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo under the pains an penalties ofpeilmy that the information provided above is true and correct. - ! - . . ._ Signature: �� w� �-� Date: Phone 4: V� . - Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSETTS BOARD OF ELEGTRICIAN:S ISSUES THE FOLLOWING LICENSE AS A RE.0 JOURNEY MAN,,;ELECTRI C I AN oc ANDREhI G L ITZENBERG 22 WEN DELL RD EXT NAHANT MA 0190$ 1129 1 1i4g6 a 6 07/31,/16 3933