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Home My WebLink AboutWiring Permit - Permits #13154 - 91 FULLER ROAD 3/12/2015 F Date: ::. ........... ................. A0RTjj TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING 88ACHU5� This certifies that ... ••••••••• has permission to perform.. 1 ;.`:....° ` � s wiringin the building of. t C .................................................................................. .............:.... : a at e J :. ." >North Andover,Mass. i ... r ...Lic No L .... . ; 9 l Fee ......... V EL I AL INSPECTOR e Check# �I }j z L - Commonwealth of Massachusetts Official Us Only a Department of Fire Services Permit No. Occupancy.and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (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 WINK OR TYPEALL INFORMATION) Date: 3 ► o _ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) C-/ tf��pr. r � Owner or Tenant E// Telephone No. 97r &`16,f-2 a Owner's Address _ 19 yn P . Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 1(-."J-(X e i, ,-,, o /�,�� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ 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 of the ollmvin table may be waived by the Inspector of Wires. \ No.of Recessed Luminaires I No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA \� No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting 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 InitiatingTotaDevices No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No,of Dryers Heating Appliances KWSecurity Systems:*. No.of Devices or Equivalent No,of Water I No.of No.of Data Wiring: Heaters Si 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 as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 3 _Inspections to be requested in accordance with MEC Rule 10,and upon completion. rf INSURANCE CO RAGE: 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 ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjt!ty,that the information on this application is true and coltp/ete. FIRM NAME: f 6C C > LTC.NO.: ( d Licensee: t� �/r �CG� l< Signature LTC.NO.: (Ifapplicable,enter`exempt"in the license number line.) Bus.Tel.No.;92& Ef!t �f Z Address: 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)❑owner ❑owner's agent, Owner/Agent Signature Telephone No. PERMIT FEE:$ FLE(CQ;'Ale?e_' — _ L+L�G`7C`.�.�LGY.1�.1Cr��'.L+'+L��'OJ�'.•• . - - • �'_ • , Re-inspection requirecT($50.00) inspectors'c eats: nspecto Signs re-ouo knitials) _ Date Z.�+SCT�.A-C,J0t7s1'�C7�x01�'a 'assed- [ MUCCI--[ � �e xnspeetlon xe0uired($50.00) [ � -- Znspet:tors'coxnmtextfis: • XA4ectors'Signature-•.ao ist3ttials) Date 3,TINDER GRODND XN'gRMCXON: passed—( 7 Sailed- [ Re-inspection xeguixell($50.00)�[ ] xnsp actors'comments: (fuspectors,Signature•-uo initials) Date 4.IN'S.PECUON'•-SERwCE: - rATiEi<_ltL 1a— �IA±ONA Ott : NAMM:. 3?assecl--[ x Sailed--F e�inspectionxecuired( 50AD) �'nspectbxs'eoxame�afs: okspectors'Signature•.no initials) Date �'assecT--[ ) p'aitecT--[ ). •lie inspection,xeguixed($50.00)�[ � �E pixsieetoxs'coxnmextts: Qhsp Bettors,Signature-710 Wflals) date )DO OR TAGS AM TO DE T+'ff ,ED OUT.AND LEFT ON SITE U+`THE:AREA.TO DE WSPECT'ED 19 TOT .ACCENSXBEE AND.A MWSPECTZON O)T$50.00 IS TO DE CMRGED. The Commonwealth of.Massachusetts - .Department of`Xndgstz ql Aeddcl is Office of Investigations 600 Washington.Street Boston,MA.02111 10 wwmwass govIdla Woxkersi Compensation Insurance Affidavit: builders/Con>ractor$/EX ctricPleas �'xinl Tmeb)r �,.ppjitcan.�Zinfoxmatiton Name(BusinessiOrganizationtfiidividual):^ r 1 r✓ L6 i" k-C4 City/State/Zip: P Cs/P kv-, Are you an employer?Check the appropriate box: Type of project(required): i.. i am a employer with 4. ❑ x am.a general contractor and I 6. ❑New construction. F employees(full.and/orparE part-time),* have,hired the sub-contractors 7 A Remodeling 2, I am a sale proprietor Or partner- listed on the attached sheet. These sub-contractors have S. [(Demolition ship and'have no employees workers'comp.insurance. -, working forme in any capacity. p 9. ❑Building addition [No workers' comp.insurance 5. El ,�We are a corporation and its 10, (Electrical repairs or additions officers have exercisedtheir required.] ri bt of exemption or MOL 1111 Plumbing.repairs or additions 3.C( Z am a homeowner doing all work g p p 12,�(R o of repairs c. 152,§1(4),andwo haven myself. PTO workers comp. employees. o workers' insurance required.]i13.0 Other comp,insurance required.] xAny applicant that checks box#1 mustaiso fill outthe section below shov&gtheir workers'compensation policy information. ?'Homeowners who submit affidavit indicatingthey hie doing Awork`and then hire outside contractors must submit a new affidavit indicating such. xContractors that cheelcthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'corrtpensation insurance for my employees: .Eelow is the policy and jab site information. Tnswanco Company Name:. Policy#or Self ins.Lic.0: 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 requiredunder Section 25A.of MOL o.152 can lead to the imposition of criminal penalties of a flue up to$1,500.00 and/or one-year imprisonment,as well as civilpenalties in the form of a STOP-WORK ORDER and a fine of up to$250.0 0 a day against the violator. Be advised that a copy of this statement may be forwarded to the office-of Investigations of the D7A for insurance coverage verification, X do Hereby cent under thepair2s anrlpenalties ofperlury that the information provided above is trice and correct: �f`7 Date• 3 % gn �•%r/ Siature ( Y,� offtcial 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): X.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing inspector 6.(Other - Contact Person: Phone N. ONIMONWEAL®M OF MASSACHUSE, -T• Bomb :' E.LECTRICIANS z, ISSUES` THE FOLLOWING LICENS GIE,. AS JOURNEYMAN ELECTRIA 1� d I EDWARD A KANKA J►� 1 t f y 147 MI LLy1LLE ST LEM.: o3079 2221 G` . Ji 61010