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Home My WebLink AboutWiring Permit - Permits #12690-1 - 80 FLAGSHIP DRIVE 9/17/2015 Date.... /. ../�... �pSORtI�q - of : .'•�°o� TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING 88ACHuss i This certifies that has permission to perform wiring in the building of....,_ _ . ....In. .,N ... at ... ....�� °,. .�1P�:. ...........................................North Andover,Mass. � f Fee, ........Lic.No ......................... i ELECTRICAL INSPECTOR Y I Check# p2k� -r ial tT ic 0/Madjacliuielh Ur se ly, Permit No. 2epadm-ent olj4re Serviced Occupancy and Fee chccl<ccl BOARD OF FIRE PREVENTION REGULATION& [Rev, 1/07] (leave. blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR Vr All Nlork to be perroylile(l in accordancelce with the Massachusetts Electrical Code (MEC), 527 CMR 12_00 (PLEASE PRINT j At jAiK OR TYPE ALL INFORAlfA TION) 1)atc: City 01- Town of': " - -viva-. ---- To the-l—i?spe-clo' i, of Wires: By this application tile undersigned gives notice of his or her intention to perform the, electrical work described below, Location (Street & Number) So - Olviler or Tenant Telephone No, Owner's Address Is this permit in conjilrictioll with a building permit? Yes No-m—(Clieck Appropriate Box) Purposeof'Building 7M,AV�A.r:11 Utility Authorization No, Existing Service Amps Volts Overhead Undgrd [:1 No. of'Meters New ServiceX Amps Volts Overhead Number of Feeders and Anipacity Undgrd ❑ No, of Meters Location and Nature of Proposed Electrical Work; cu COTEle(ion of t�iY2llorving table ma be ii,ai- (lie No, of Recessed Lt ininaires No, of'Ceil,-Susp, (Paddle) Falls No, of Total J-1 Transformers KVA No, of Luininaire Outlets No, ofl-lot"rubs Generators I(VA T/-- 'y T,-1gT,11-11-g I No, of LuminairesSwimming Pool Above R In- • 211111(l. Battery Units No, of Receptacle Outlets No, of Oil Burners FIRE ALARMS jNo, of'Zones No, of Switches No. of Gas Burners No, of Detection and Initiating Devices No, of Ranges No, of Ali, Cond, oils No. of Alerting Devices - No, of Waste Disp(sers Heat Punip I N.lpp,l?,er ';�qps IKW No,-oT9-e-1f-T`ontaFn—ed 'i o n/ 'e"it" 0 Totals: Det ction/Ale vices o a 1pq C!io "p r" D Otliel. No. of'Dishwasher s Space/Area Heating KW Local C ull, tioll ollnee See Systems; Security Systems: No, of Dryers Heating Appliances KW F evic or No. of bevices or Equivalent No. of 0. of, Heaters I(W Ballasts Data Wiring: Ins No, of Devices or EqUiValent No, Hydromassage Bathtubs No, of Motors Total lip -relecoinnitiiiication,,,,-VFiriiig,----- No. ofDevices or Equivalent 4-- OTHER: J Attach additional detail if desired, or as required by the Inspector of Pflires Estimated Value of E lectric"al wol-kA w, occ" (\�rhen required by municipal policy.) Work to Stai,(: Inspections to be requested in accordance with M117C Rule 10, and upon completion. INSURANCE COVERAGE: Unless waive(l by the owner, 110 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, Cl-fECl( ONE,: INSURANCE El BOND [-] O'FFf.FR E] (Specify:) I certify, under the pains andpenalties ofpeijury, that the information on this application is true and complete. FIRM NAME: Amore Electric, Inc. LIC. - -tItl Licensee: Anthony Amore Signature NO,:Al 5375 (If opphcablvnxer llegrb,in t(Pe4ense Bus.Tel, No,:97T-3725877-- Address: Vco ni averWil n,�UX Vf�35 Rico, Alt,Tel, *Per M,G.L. c, 147, 57-6 1, 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-noi-in"alh/7 required by law, By ny signature below, I hereby waive this requirement, I an-i the (check one 0 owner El Owner'saulit. Owner/Agent Signature Telephone No. PERMIT FEE,- $ 0 B09/17/2015 10: 39AM FAX 00001/0002 The Commonwealth of Massa Nk z�4 Chusetts �.�,��,,r'P�1r�;tcVbrrrr��;�% Department of Industrial Accidents ' Office of.fin vestigations I Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov/dia wod ers' Compensation Insurance Affildavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(13tisines/organization/lndividual):Amore Electric, Inc. Address:65 Avco Rd. Unit F City/State/Zip:Haverhill, MA 01835 Phone#:978-372-5877 Are you anlemployer?Check the appropriate box: Type of project(required): 1.0✓ I am a'employer with 17 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am ajsole proprietor or partner- listed on.the attached sheet. 7. Q Remodeling ship and have no employees These sub-contractors have g. Demolition worki'g for me in any capacity. employees and have workers' insurance.$ 9. ❑ Building addition con [No workers' comp. insurance p. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I atn aihomeowner doing all work officers have exercised their I LED Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12_❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' — . comp. insurance required.] ' Any applicant that checks box#1 must also fill out the section below showinb their workers'compensation policy irtfonnation. t Homeowners who submit this affidavit indicating they urc doing all work artd then hire outside contractors must submit a new affidavit indicating such. IContructors thatichcck this box must attached an additional shcct showing tiie 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. 7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. ; insurance Co>jriparty Name:Associated Industries of MA Mutual Insurance Company Policy# or Self-ins. IJc. #:WMZ 8005862012015 Expiration Date:07/01/2016 Job Site Address:80 Flagship Drive, North Andover, MA 01845 City/State/Zip:Boston, MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), Failure to secure coverage as required under 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 D1A for insurance coverage verification. l do hereby erti under the pains and enalties of erju that the in ornratinn provided above is true and correct. misty Forrest _ Date. Phone#: 978-372-5877 Official Ide only. Do not write in this area, to be completed by city or town official City or Tt wn: Permit/Licence! Issuing Aiithority(circle one): 1. Board oi'Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact P rson: Phone#: <:COMMONWEALTH OF MASSACHUSETTS BOAF{l� ELEC<TRICfANS ISSUES :THE FOLLOWING LICENSE AS..'..--.A:. REG JOURNEYMAN:.ELECTRICI.AN (cc Q ' Z PAl1� M B L A I S 47 BEDARD AVE �W U BY NH 03038-4214 _. 31237 o7I31116 77351