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Home My WebLink AboutWiring Permit - Permits #12038 - 25 FERNCROFT CIRCLE 12/5/2013 Date ................. r►ORT#f •° •'� TOWN OF NORTH ANDOVER j PERMIT FOR WIRING so BB�CHUg� ;^ This certifies that .. a .....E� ` ...........0 8 r a has permission to perform � ..� ................. ......... ............................. wiring in the building of.....y .� ............................................................ z P_Qorlh Andover,Mas at .... pIF . eA_Ci Ei44 •. ••. Fee...:.... ..................Lic.No..:..,;............ EL INseacr0 Check# " _ (fnmonwea&of Madjaclwattj Official Use Only Permit No, Apartnwnt ol5ire Serviced BOARD OF FIRE PREVENTION REGULATI Occupancy and Fee Checked ONS! [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CN4R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAIJA TION) Date: ,I — City or Town of: \\)o,, To the Inspector of[Vires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) �'S it vi crci C Owner or Tenant N\, M , r Telephone No. Owner's Address �'k Cs -P ( A'',m Is this permit in conjunction with a building permit? Yes No (Cliecl'i-Appropriate Box) Purpose of Building 0 r ,0,&c G ,rt�, Utility Authorization No. W �S'�05- Existing Service Amps Volts OverheadD Undgrd❑ No.of Meters New Service X Amps Q u Volts Overhead UndgrdF1 No.of Meters Q Number of Feeders and Anipacity Location and Nature of Proposed Electrical Work: C3 Coin pletion of thefiolloiving table inay be waived hy the Inspector of!fires. N .of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Troansformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above o In- 1:1 of Emergency Lighting 40 gl-nd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones re ot'Detection and 7� No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tonal No. of Alerting Devices Heat Pu p I N.ppjber..j,Ton,s No, of Self-Contained No.of Waste Disposers Totamis: IDetection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local E] Municipal F Other J_ 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 or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: Attach additional detail if desired, or(is required by the Inspector of 11"ires. Estimated Value of Electrical Work: (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"covet-age 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 KI BOND F] OTHER F] (Specify:) I certify,under the gins andpenalties ofpetjuty,that the infortnation,on this application is true and complete. ...... FIRM NAME: Amore Electric, Inc. LIC. NO.: Licensee: Anthony Amore Signature/ 15375 NO.:A . 11 — -372-5877 (1fapplicablvIel eg�pG in.f4ense nwiVr h Bus.Tel.No.-978 VC0 a N.�35 lk IL Address: Alt.Tel.No.:52 *Per M.G.L.c. 147,s.57-6 1,security work requires Department of Public Safety"S"License: Lic.No. psi OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance covet-age normally required by law. By my signature below,I hereby waive this requirement. I am the(check one [:]owner El owner's agent. Owner/Agent Signature Telephone No. Fp_EItM_,T FEE: $ 9 The Commonwealth of Massachusetts I Kill 7PeftiF°r'rn- �� Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Inc. Name (Business/Organization/Individual):Amore Electric, _ Address:65 Avco Rd. Unit F City/State/Zip:Haverhill, MA 01835 Phone #:978-372-5877 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓❑ I am a employer with 15 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 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. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ 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 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Associated Industries of MA Mutual Insurance Company Policy#or Self-ins. Lic. #: WMZ 8005862012012 Expiration Date: 6/15/2014 Job Site Address:25 Ferncroft Circle City/State/Zip:N. Andover, 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of er'ury that the in ormation provided above is true and correct. � Dlgl Vysign byKrlsryhrtest risty Forrest �� =w„�Fo.,<,�o- ,.Ek�k,,M.o �,. 12�4/13 A-Ido�,<,tt amoee¢k<irkcwm.�-US . Signature -- e,3n,o„s,3,.«� --._____ Date: — Phone#• 978-372-5877 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 Cleric 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: o COMMONWEALTH OF MgSSACHUSETTS ® ® ® ® ® BOA�tk�f;3F ELECTRICIANS J. ISSUES THE FOLLOWING LICENSE AS A" !12EG JOURNEYMAN :ELECTRICIAN 0E PAU>Y M BLA I S ' 47 BEDARMAmmwD AVE MERV DERBY NH 03038 4214 123 E< o /31/l6 77351