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HomeMy WebLinkAboutWiring Permit - Permits #11597 - 80 FLAGSHIP DRIVE 5/20/2013 h- r .... Date :, ANDOVER NORTH ,tip TV YO N OF N®RT PORING �.•. :` PERMIT FOR 8�n•nu� � ' 8.4CHU8 - a ................ This certifies that .. •• �,. .:r, ssion to p erform ... .. A W , has perms ............. E � � .. wiring in the building Mass. �. .. And over,M �a CAL INSPECTOR j Lic.NO ELEam r Fee. Check# f Commonwealth of Massachusetts Official Use Only Department of Fire Services`V/Ce9 Permit No, ' 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(NM,Q,527 CMR 12.00 (PLEASE PRINT IIV MK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the In pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �J /���� Owner or Tenant ( / GiiylSi _ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate]Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1;;�V,o C/ Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA \ No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets ;L No.of Oil Burners FME AT No. of Zones No.of Switches No.of Gas Burners No. of Detection nndInitiating Devices No.of Ranges No.of Air Cond. TotTons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.ofSelf-Contained P Totals: ..... • .............................-.... Detection/Alertin Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent,_ No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of fires. Estimated Value of Electrical Work: /I (When required by municipal policy.) a 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: J&Z%i-Oc �Z •� SE�'z%c�'" LIC.NO.: 4if�'S�� Licensee. Signature LIC.NO.: `33,e .,3 (If applicable nter "exempt"in the license number line.) • Bus.Tel.No.:��������� *Per M.G.L 47,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 xequired by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Please Print Lel;ibly Name(Business/Organization/Individual): Rkl;,�C Address: City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1..© I am a employer with_ Z 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.®Electrical repairs or additions required.] officers have exercised their 3.❑ I 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,❑Roof repairs insurance required.]; employees. [No workers' 13•1—i Other 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 submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors 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. Insurance Company Name:. Policy#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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and'penalties of perjzny that the information provided above is true and correct. - Si nature Agi Date: 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#: COMMONWEALTH OF MASSACHUSE`-TS AS A REG JOURNEYMAN ELECTRICIAN. ISSUES THE ABOVE LICENSE TO: MATTHE:W R BRIEN z 20 MYRTLE STD METHUEN MA 01844- 130 33623 E 07/31/13 831638 Commonwealth of Map!setts Division of Registratio $ Board ofElectri MATTHE-9 20 MYRT�E METHUE w b Master Ell ecl.i 'a 21169-A s 07/31/2013 006526 License No. Expiration Date. Serial No. i 'r i