HomeMy WebLinkAboutWiring Permit - Permits #12590 - 55 FOXWOOD DRIVE 8/6/2014 i
Date ' . .. ...............
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TOWN OF [NORTH ANDOVER
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PERMIT FOR WIRING
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:. :� `This certifies that .��..r�.: ;,��� � ... .......................................................
has permission to perform
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wiring in the building of ...... . .. ��.. .:..� :.`............................:...............................
at .. .........9 : ....� ...::.. '...... ti L .............. h Andover,Mass.
Fee......tea ..............Lic.No 7`.� .' .. ... . .........
-- ELE L IN OR
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Check# �f --
Commonwealth of Massachusetts officill, se 0 lb
Department of Fire Services Pert-nit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
lug [Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: A&wa,5-� '1, 1 5)&11,1
City or Town of: NORTH ANDOVER To the Inspecdv of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number) "s 1-6J(-U.It�,,�,J '2
Owner or Tenant tt v Gti Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes Dq No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service,22�_ Amps /-,)-0/ 3�/-OVolts OverheadE] Undgrd E No.of Meters
New Service Amps Volts Overhead R UndgrdF-1 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical-e Work:
A P, � a,,,r, - - - .3---2 y
Corn pletion qf the lblloiving 1611owing able inay be vilaived by the Inspector qf'Wires.
No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of TotalTransformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above o In ot Emergency Lighting
gi-nd. grnd. " Battery Units
No. of Receptacle Outlets 7 No.of Oil Burners FIRE ALARMS INo.of Zones
No. of Switches No.of Gas Burners No.of Detection and
Initiating Devices
Total
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
Municipal F-1 Other
No. of Dishwashers Space/Area Heating KW Local El Connection
No. of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No. of Water No.of No,of Data Wiring:
Heaters KWSigns Ballasts No.of Devices or Equivalent
No.Hydromassaue Bathtubs No.of Motors Total HP Telecommunications Wiring:
1 No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector qffires.
Estimated Value of Electrical Work: 1,)C)6),ad) (When required by municipal policy.)
Work to Start: PZ2 1:2o Iq 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 VN- BOND F1 OTHER F] (Specify:)
I certify,under the pains and penalties of perjury, that the information on this application is true and coinj)lete.
FIRM NAME- I - // LIC.NO.:
1-' c c
Licensee: Di1 ll, (IXM / )(-)V? e!I Signature LIC.NO.:
(If applicable enter "exempt"in the heense neinblr h ) Bus.Tel.No.:
Address: �)*, the
0�11 Alt.Tel.No.:
*Per M.G.L c. 147,s. 57-61,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 F] owner El owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No. F
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x"he commonwealth offfass'ach.usells "
Dep artmen a, r` s �zccl ccxc e �
Office of I n•vesfigaflons
Ella Washington Street
Boston,MA 02111
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` orkexc$'Comp eace'a€ioxa.bsurance Affidavit:
33�c�ex�lCod£�ac�ax�CEXeo�rczeza��l�'���?e�',�
A ear+ orana on r Ploase.Pr�kt�e�.bk
Name(Bus3nesslorganization&dr'4 dud):
Address:
city/statomp: A1/1,21,,e"I,�) ov'(:�/,P" phonolh—
Ar c)your au employer?Cb.evkthe aPproYdate*aox: Typo of project(yeguixed):
1.0 I am.a employer with 4. El x ata a general contractox and 1 6. [1 New 0611stru060n
employees ft"llan.c(oxpax'u tim.e)* havoliixed.th.o sub-contractors
2. 1 am,a sole proprietor ar partner
listed on the attacb.ed sheet.t 7• �(R.exaodaling
ship and`liavena•employeos These sub-contraetorshave 8. El Demolition
workers'comp.insurance, g, Buffi addition.
woxlCing 1'arme in any capacity. � 8
Pb workers'comp,insurance 5, El we axe a corporation andits 10 Electricalxepairs or additions
required.] officers have exercised.theix
light of exemption tion erMOL 11..�(i'lumbingxepaixs or additions
�3.El x am.a homeowner ping all wort myself.LEb workers c comp. 52 a§I( )a and w h verso 12.P Roof'xepaixs
iasuranc�xeslrrzixxed.�i employees,[No workers, 13,0 Other
comp,insurance required.]
Any applicant that diecks box#1 must also fill outthe seof!on bobw showing their workers'eomPensationp el!cy information.
i-Homeownerswhosabmittbisaffidavitindicatingthe a(;doing Aworkandthen hire outside contraetorsmustsubmit anew affidavitindicatingsuch.
xContracfors�7iat ahecktius bob mast af#ached an addifionat sheet showingthe name o£the suh-eonfracfors and their workers'comp.policy information,
taxnax2exnpXayeN that zsp avzc�% g osXrer 'cornpeiisationinszcraneeformyemTloyees Below bthapo.11eyanrjohsite
in,fDx�xnatio�.
lusurance CompanyNam.e:.
,. Policy#or:Self�ins.11ic.#: ExpirationAate;
Sob Site.A.ddreso' City/State/dip;
.A.tfacb,a copy ofth.e workers'comp ensatzo)a-policy declaration page(showing•tb.e Polley nmbOr and OXVixatiou.crate).
yailmo to secures oovoxage as xequm6dunder Soction 25A,ofMGL o.152 can lead to tho imposition of cximinalPenalties of a.
fine up to$1,50 O.o o andlox one year hnpri-90PmentA as woll.as civU penalties in the form of a,STOI'W ORT,ORDER,anal a fne
of up to$250.00 a day against the violator. Be advised that a copy ofthr's statem•entmayba forwardedto the Office of
Investigations oi~the DfA.for insurance coverage verification.
y 1Y e azns rt rt ena d P t rY '
p t s o er'u treat tXae in ormation r o�zctecX a ove s t�ua a eo�t
,�'rZo XtereXr certari er
Si ature: � '�l `, s .. Date.
r
Phone#:
OfficzaZ use oply. Do not write Al gis area,to be eonVfeted ry city or town ofclaf
City or Town: PermliffiiceRse#
Issuing Authority(circle one :
1,Board of Health 2,Building)DOPartmeu.d 3.dCityJTovm Clerk 4.Electrical lluspector S.NumbingfusPector
fi.Other
COMMONWEALTH OF MASSpOHUSETTS
BQARQ OF
LECTRIGIANSI
ISSUES THE FOLLOWING LfCENSE 'AS A W
REGI:STERED MASTER ELEGTRICIA�f
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Wf LL 1 AM F COON,EY W
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28 COMET RD
METHUEN MA 01844-5604 a
21292 A.` 07131-' 56946
COMMONWEALTH OF MASSACHUSETTS
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HOARb OF
E1;E . I C I ANS
ISSUES THE FOLLOWING L'IGENSE
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AS .A REG JOURNEYMAN ELECTRICIAN
WIL_LI.AM F COONEY A.
W
28 COMET.. RD •�
METHUEN MA o i 844=5604 .
38028E . .. 07131116 27324
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