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Home My WebLink AboutWiring Permit - Permits #12868 - 38 FARNUM STREET 11/3/2014 Date.... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................ ........................ .................... has permission to perform .......... ...... ..... .. ......................... ................... .......... . .... ... e...................... ...... . ......:......................................... wiring in the building of,,� North Andover,Mass. ............... ................................. ......... F ce... Lic.No. ... ....... .... ........ ;,CT ,AL INSPECTOR Check# o/ ofticialuseunly 2epaptment 0131.,Serylcm Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS pv.1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance,with the Massachusetts Electrical Code WC),5 7 C 12.00, (PLEASE PRINT.RV NK OR TYPE ALL rlff, MTIOM Date: City or Town of: To the Inspector of Wires: V, By this application the undersigned'givedn notice obis or her intention to perform -k described below. Location(Street&Number) GJJ C Owner or Tenant 1: Ye CR Telephone No. Owner's Address Is this permit in conjunction with a K building permit? No ❑ (Check Appropriate Box) Purpose of Building �) 6�, Utility Authorization No. <; — Existing Serv1ce_%,,so Amps /.P4/,ayo_YoltS Overhead r] UUdgrd No.of Meters New Service Amps Volts Overhead r] U.dgrd r] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (A V, Completion of the following table may be waived by the Inspector of Wires. No.Of_ Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers... KVA Na.of Luminalre Outlets No.of Hot Tubs Generators KVA Above n No—.5Tffm—er_gen_eyTi-9fft_1n_9 No.of Luminaires Swimming Pool grnd. ❑ grnd. Battery Units No.of Receptacle Outlets (I'll No.of Oil Burners FIRE ALARMS No.of�'ones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Re—atPi[Tim- -Contained ta p .......... No.of Self lf� �Detection/Alertin Devices Totals: No.of Waste Disposers Local❑ 'MunicipalF1 Other No.o'tDishwashers Space/Area Heating K 0 W Connection Security Systems: . Na.of Dryers Heating Appliances KW No.of Devices or Equivalent ...... No.of Water No. Data Wiring: Heaters Signs KW Of No. No.of Devices or Equivalent 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 Wires. Estimated Value of Electrical Work: (When required by municipal policy.) completion. Work to Start: Inspections to be requested in accordance with NIEC Rule 10,and upon -comp 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 0 OTHER n (Specify:) I certto,under thepai4spndpenalfles of perjury,that the information on this application is true and complete. LIC.NO.: FIRM NAME: e`o, Si storeLIC.NO.: L Licensee: :4&VIC Bus.Tel. ff applicable,enter "e in t fl nse umber line) ,Joe mo�, -L 1,d'> /" Alt.Tel.No.: ........ A1,1/> Address: "S"License: LiG.No. D. *PerM.01. . 147,s,57-61,security work requires Department of Public Safety insurance e ge rmal y OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabilitycoverage no required by law. By my signature below,I hereby waive this requirement. I am the(check one)El owner E]owner's agent. Owner/Agent Signature Telephone No. �� G� �i-u- , yP�, � The Commonwealth of N.t"assachusetts - " .Department of Xndustrigl Aceldiinis Office of Investigations 600 Washington Sheet Boston,.NIA 02111 www.rmssgovlriia ''Workers' Compensation Insurance Affidavit:Suffders/Coy.tractors/Blectricians/Pli ba*ber,4 .A•ppXiieaut Information Please Print,Legibzy Name(Business/Organizationlfndividual): ry w :, m ~�a J�� 5 Address: City/State/Zip: ' t> �' .. Phono .Are you an,employer?Check the appropriate box: Type of project(required): 1,[] I am a employer with 4. ❑x am a general contractor and 1 6. ❑New construction f exla 6yoes(full and/or part t7t o).* have hiredthe sub-contractors 2. am a sole,proprietor or partner- listed on the attached shoat.x 7� Remodeling ship and'bave no-employees These sub-contractors have 8. Cf Demolition working for mein 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.[1 Z am a homeowner tilting all work right of exemption per MOL 11 L E(Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),andwehaveno UPRoofrepairs irtsusancere iced. employees.[No workers' a 13.0 Other comp.insurance requiredJ 1%ny applicautthat checks box#1 must also fill outtfie section beldw showingtheir workers'compensatlonpolicy information. i'Homeowners who submit this affidavit indicating the$are doing all work and then hire outside contractors must submit anew affidavit indloatiirg such. tContractors that cheAthis box must attached as additional sheet showing the,name ofthe sub-contractors and their-workers'comp.policy information. fain are employer that isproviding workers'compensation insurance formy employees Below is tiiepol"iey anrijoh site ir?foxranatiorz. Insurance Company Name:. Policy#or Sol£ins.Lic.#: Expiration Date: lob Site Address: Pity/State/zip: Attach a copy of 0o workers'comp ensationpolley declaration page(showing the policy number and expiration.date). Yailure to secure eoverage.as ro(lu I're dunder Section 25A ofMCL o.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/or one-year imprisop ent,as well as civil penalties in the form of a SWOP WORK ORDER..and a fine ofup to$250.00 a day against the violator. Bo advised that a copy of this statement may be forwarded to the Office of favestigations ofthe DIA.for insurance coverage verification. Xdo Barely eert&under fizepazns and enaXties gfperjury that the information provided above is true and eo.erect, sip afore: „ mod_ Data: a Phone#: Official use oily. Do not write in this area,to be completed by city or town of"cial; City or Town: PerniMicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CIWT- own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Pers on: Phone N., ,f l 1 # .COMMQNWEALTH OF MASSAGHUSETTS ..: ROB E ELECTRICIANS ,§SUES THE 'TOLLOWING',L,1 NSE AS,, q 4 W RI GfSTERED MASTER ELECTRICIAN: �c` GOS3ANIAN ELECTRIC zVEN J , OSTAt�[IAN 32 BRADF..ORD 'AVENUE ,s ; ,_ .w' e HAVERHILL MA 01835-7242 ' 18202 ! , ..07/31/16 ; 27240