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Home My WebLink AboutWiring Permit - Permits #11537 - 70 FLAGSHIP DRIVE 4/24/2017 : Date..... Mi .�................... 4 t o¢'jORT",�ti TOWN OF NORTH ANDOVER a PERMIT FOR WIRING 88ACHUg� l'. 8 E ii pp ................. .. ............................ .. This certifies that ...... .. C s .... s ' Es e has permission to perform ...�l� ••• � . ! � wiring in the building of..................... 1.t........... ov .. �9 R.: .... �� ...... ,North Andover,Mass at Fee Lic. ax No ..............ry.. ... ELECTRICAL INS PECTOR Check# __-__---- �E', SUSAN PEARSON<sspearson@mac.com>(i April 12, 2O 13 7:36 PM lb. susan.stcpllen Ix:rrsonC>>c)m ril.corrr SCN_0006.pdf n pp �X ry� Comrnonwea[t�i o`rrlaee A.jelh c7 �eParintenl o/,yire Services PermitNo. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev.1/071 leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perforated in accordance with the Massnchuseus Electrical Code(MCC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAIATION) Date: 'A—A4--k City or'I'own of: NDJr , /4,,t16.,�- 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) -71" f1h,4;ki, OL _ Owner or Tenant 111„1�1,o 'A,ff14l Telephone No. Owner's Address �U Flf,i Stun IN- 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 y New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the followingtable may be waiver)by the larpeclor o lVires. No.of Recessed Luminaires No.of ceil.-Susp.(Paddle)Fans o•of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA f No.of Luminaires Swimming Pool Above n- o.orYmergency Lighting a rnd. rnd, Bottery Units No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No.of Zones o.o Detection an No.of Switches No.of Gas Burners Initiating nitiatin Devices No.of Ranges No,of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat ump Number Tons W o.o 'e - onto tied tosers Totals:I Detection/Alertin Devices No.of Dishwashers S ace/Area Heating KW Local❑Monti ti Other -- P g Connection Dryers Heating Appliances KW Seeur ty ystems: No.of Dr 5 No.of Devices or Equivalent L� o.of Water o.a o.o Data Wiring: Healers KW Si ns Ballasts No.of Devices or E uivalent No.H dromossa a IIalhluhs No.of Motors Total HP a ecommun cat ons r ngg: Y S No.of Devices or E ulR.T.I: OTHER: Attach additional detail if destred,or as required by the btspecrar aI fl'ires. Estimated Value of Electrical Work: �'zC'(,'D,c°(' (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 Nd BOND ❑ OTHER'❑ (Specify:) I certify,under the pal w andpnmlties ofperjury,!l t t/re ujonnatlon on this application Is true and complete. FIRM NAME: G � O C% �a I.iC.NO.: ,.t2SG�, ! Licensee:_��_ ar'b tt Signature ap .p� LIC.NO,:-�� (Ifopiah'able,entertt"exenr,t'in Ity lice t se aumher d/irte.J Bus.Tel.No' Address: -1 Address: ��1.� j 7 C�(1_ '• b!"wy0 �`ACt Alt.Tel.No,:_laIS: *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 El owner's agent. o Owner/Agent p�RMIT I EL:S f` t� Signature Telephone No, ( The Commonwealth of Massachusetts Department of IndustrlalAccWhts 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 Le0bly Name(Business/OrganizatiorAndividual): i-Sc7 s, F_Gp xsC_, Address: 3 LL �Jo �o• ,, , end ,P4,;�- City/State/Zip: W o-b cooQ Phone#: ZnAre you an employer?Check the appropriate box: Type of project(required): 1.❑ I 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.bQ I am a sole proprietor or partner- listed on the attached sheet. 7 ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.t4 Electrical repairs or additions 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.]r employees.[No workers' 13.❑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 6e 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. 1 1 Insurance Company Name: 1Am !p®y-e-c- Policy#or Self ins.Lic.#: Expiration Date: (� Job Site Address: D -RQ a 6 1 C City/State/Zip: �_ N40 o@_ Attagh 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and enalties of perjury that the information provided above is true and correct. Signature: Date Phone#• L kI-) — l— 'tl 9 `�— Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: x. TM E q$OV LICENSE TO. ECTRIC �ARSOt 1 STD` ht " • EXEC JCIANS''; AS A RF-C:Jt}URNEYMAN �LECTRICIA ISSU SJHE ABOVE LICENSE TO: K `� j ' `vybF'fl-N J :PEARSON, S T 1iQ MA ,02,962-27i