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Home My WebLink AboutWiring Permit - Permits #12548 - 110 FARNUM STREET 7/31/2015 Date... �®tlY ANDOVER O�NONTN��O TOWN Oi'tw F NORTH o� ; p PERIVII7 FOR �/IRIMG 88ACMU`3 brY i ........................... This certifies that has permission to perform :.• ••.•••.•• ............ airing in the building of Mass. �� .. .. .� No Andover, "at ' 1 �i ® Z 1C.Nod ELECTRICAL INSPECTOR Fee......... ................. Check# { low (fommonwea&of Mamachudeltd Official Use Only 2c'� �c77 c'� Permit No. �� t eparEmenE ol5ire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank] APPLICATION FOR PERMIT TO PERFORM ELEOTRIC-AL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR812.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR TION Date: City or Town of: ®� � � � To the Inspector of Wires By this application the undersigned gives.notce of his ar her intention to perform the electrical work described below. Location (Street&Number) Owner or Tenant j_L Telephone No. ry Owner's Address w Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 2-6,0 Amps / 21/6 Volts Overhead El/ Und rd g 0 No,of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion ofthefollowing table may be ivaivedby the Inspectorof 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 Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd, ❑ rnd, ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond, Total No,of Alerting Devices Tons No.of No.of Waste Disposers Heat tamp Number„T ns „•,,,,,,��'•,•,.,.... Detection/A`lerttn inDevices No. of Dishwashers Space/Area Heating KW Local❑ Munlcipal ❑ Other Heating Appliances Security Systems:* Connection , No, of Dryers g pp KW y No.of Devices or Equivalent No, of Water KW No, o,of Data Wiring: Heaters Signs Ballasts No,of Devices or E uivalent l No. Hydromassage Bathtubs No,of Motors Total HP Telecommunications firing: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electr' al Work: (When required by municipal policy.) Work to Start: ( rInspections to be requested in accordance with MEC Rule 10,and upon completion, INSURANCE GE: 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 covefage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER [ ,�pecify:) I certify, under the pain andpenalties ofperjury,that the{lzfor. cation.on this application is true and'complete. FIRM NAME: fe LIC.NO.: Licensee: Signature .LIC.NO.: -� (If applicable,enter 'exemp "in license number line) Bus.Tel,No.: 7X"1 �i: }�(7 Address: x Alt,Tel.No.: P79 32J!�7 el *Per M.G.L.c, 147,s.57-61,security ork requires Department of Public Safety"S"License: Lic.Igo, OWNER'S INSURANCE WAIVE I am aware that the Licensee does not have the liability insurancetcoverage normally required 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. �s The Commonwealth of Massachusetts Department of IndustrialAceidents ", tl 1 Congress Street,Suite 100 Boston,MA 02114 201 7 www.mass.gov/dia SJ, Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTTING AUTHORITY. ApOicaut Information Please Print Le gib Name (Business/Orgmization/ludividua' J Address: � City/State/Zip: Af� Phone#: Are yo an employer?Check the appropriate box: Type of project(required): 1.ZI am.a.employer with_ i _employees(full and/or part-time).* 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. li Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp,insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit'this affidavit indicating they are 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 state whether or not those entities have employees. If the sub-contractors have employees,%ey must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Belolp is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify rgnder the pains andpggald s ofpeijury that the information provided above is true and correct. 1,120 Si nature: Date: Phone#: —V,�EL 5 9E-:� (;—r-2 �4�) 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH OF fVIASSACHtJSE?7S BOARt] FI ELEC;TR'I Cl'ANS ISSUES THE :FOLLOWING L.I -ENSE 'AS A� REGISTEaE0 MASTER 'ELECTRICIAN a DQUGL..AS G DAWKINS 1078 BRfl.ADWAY HAVI=RH 1 LL MA 01832 1 103' 21545. 39167 ,