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Home My WebLink AboutWiring Permit - Permits #13287 - 112 FOXHILL ROAD 5/7/2015 i Date...... p10RTjy TOWN OF NORTH ANDOVER m * ;; * PERMIT FOR WIRING CHU i, ,i This certifies that a� p has permission to perform ,........ r :2..r, ..::P' .:....... �........ wiring in the building of ....... ....................... at ........ .�.�. ..: �... .� 4L a. ........... ' Z ,North Andover,Mass. Fee.. ..y... Lic.No. � .. � ELECTRICAL INSPECTOR `" �r e Check# ` ��avf Commonwealth of Massachusetts Official Use Only ";- Department of Fire Service's Permit No. 6 3' BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy and Fee Checked ev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(WC),527 CNM 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspe&or of Wires: By this application the undersigned gives notice of his or her intention toperform the electrical work described below. OwnerorTenant [ Location(Street&Number) 4 //o A",>1 -J(,�k—! /-l. Telephone No. Owner's Address C 7>& 4/k C Is this permit in conjuue ion with a building permit? Yes ❑ No Ej (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps if Volts Overhead Q Undgrd❑ No.of Meters New Service Amps Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity L cation and Nature of Proposed Electrical Work: �tiQ°ue e . i h 0-4 Cam pletiongf the fiollo)vIngtable maybe waived by the Inspector qf Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers K- VA No.of Luminaire Outlets No.of Hot Tubs Generators ICVA No.of Luminaires swimming Pool Above M In- ❑ o mergency Lighting grud. " 2rnd. Baito'ry Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 7 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 Waste Disposers Heat Pump Number W No.of Self-Contained Totals:otals ........... T Detection/Alerting Devices No.of Dishwashers Space/Area Heating I(W Local F] Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:*, No.of Devices or Equivalent No.of Water I No.of No.of Data Wiring: Heaters m Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eaulvalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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"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 FT'BOND [I OTHER El (Specify:) of ,I certify,under thepains andpenalfies ofpeijuiyY that the ii�to�i�q!y�lon on this opplication s trite and complete. FIRMNAD4E: 5 /9, LIC.NO.:.,A615'54-`,A • Licensee:( -I"'/".dAr,)4:V,-,r 1"i't let 6 Signatur LTC.NO.: (If applicable,en�te;i "e to'in the license mt. ,line.) Bus.Tel.No.: / Address: (c, 4A-%,4e14 74 Alt.Tel.No.:!�'4 Y".. *Per M.G.L C. 147,s.57-6f,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 normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)F1 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts z Department of lndustrialAceldents •.,e P 1 Congress Street, Suite 100 Boston,AM 02114-2017 .. .}v;�°� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electlicians/Plumbers. TO BE FILE WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LelZibly Name (Business/Organization/Individual): Address: 6" .. 4VA_� City/State/Zip: i, t., Phone#: 7 V .�.... ° . . Are you an employer?Check the appropriate box: Type of project(required): 1. I am.a employer with employees(full and/or part-time).* 7• []New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition C]4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.ffElectrical repairs or additions proprietors with no employees. • 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.❑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#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. m I ant an employer that is providing ivorkers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lie.#; Expiration Date: Job Site Address: l -w w t r City/State/Zip: PO., °i imt"s el— k - 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. ,W I do hereby rM fy niter tli an nalt' perjury that the information provided above is true and correct. Si nature: . "Mw �� Date; Phone#: Official use only. Do not write in this area,to he completed by city or town offrciaZ. 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 G.Other Contact Person: Phone#: