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HomeMy WebLinkAboutWiring Permit - Permits #12366 - 32 FURBER AVENUE 5/20/2014 9 - f Date h NORT/y r° TOWN OF NORTH ANDOVER PERMIT FOR „i WIRING CHU9�� � � z This Certifies 'that ^ — 1 . a .. has permission to perform 4 1 i Af v J •• g the building of i wiring m F •,••• ..................................................... ............. ............................ ........ ............. rth Andover,Mass. Fee .........................Lic No :. . /44ALSPi' Check# ____ Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS [ 0 Occupancy and Fee Checked (leave blank APPLICATION TI MIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE.PRINT IN INK OR TYPE ALLINFORMATION) Date: `> City or Town of: NORTH ANDOVER To the Inspector of Wines: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Fur'ta,-�r Owner or Tenant �4 Ct h r Telephone No. Owner's Address _ Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building the )hyndrty &yyoc(, i Utility Authorization No. Existing Service A-V 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: W j ('4- 13 41 1 jy�� I`1�J1 Waco Completion of the following table may be waived by the Inspector of 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 No.of Luminaires Swimming Pool Above ❑ In- ❑ o,o mergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets y 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 Waste Disposers HeatPump I Number Tons KW No.of Self-Contained Totals: ""' ' ' ' """ ....."""'.""""""""'•""""' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW,:9-- ?Lqj Local❑ Municipal ❑ Other Connection No.of Dryers j Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters 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 97res. Estimated Value of Electrical Work: ��` a� (When required by municipal policy.) Work to Start: 16--0 `�Y 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 ❑AND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the inforniation on this application is true and complete. FIRM NAME: . :J-b L 60A Ce-h E -evlr,Z LIC.NO.:d-0 �/d 6 Licensee: j 0 Signature LIC.NO.: (If applicable,enter "exempt"in the license number line.) �— Bus.Tel.No.• Address: 3,� X-3h ti rn a"lud /Li) Ght/h sA rel M/1- 0 I d'2 y Alt.Tel.No.: *Per M.G.L c. 147,s.57-6 ,security work requires Department of Public Safety"S"License: Lie.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 PERMIT FEE: $ ✓ Signature Telephone No. _ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 §Rule 8 In accordance-with the provisions of M.G.L.c.143,§3L,the Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chanter240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act.furthers this Purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extendin g'through August 15,2012, ❑ Rule 8—Permit/Date Closed: Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Ins ection Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass(]' Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n? Failed 0 Re- Inspection Required($,)❑ Inspectors Comments: Inspectors Signature: Date: , ROUGH INSPEC ON: Pass M Failed Re- Inspection Required($.)❑ Inspectors Comment �C I Inspectors Signature: Date: 'INAL INSPECTION: Pass M Failed L7 Re-Irhspection Required($.) ❑ nspectors Comments: Inspectors Signature: Date: :B WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ^ The Commonwealth of n2'assachusetts Department ofXndustrigl Accidats Office of Investigations 6#0 Washington Street Boston,.MA 02111 vow.mass.govIdia Workus'Compensation Insurance Affidavit:Bulltiers/Conti°acforoMectriclans/J.'hi bens AppReant formation, Please Print LegibXy NaMo CBusiness/Organizationitdividual): 6 ►A Q�-e-M Address: � � �n�vn ee, ,�v City/State/Zip: G' ��s a-�� Yam- d I Phone#: 91 )d,- -VV00 Are you not employer?Check the appropriate box: Type of project(required): 1.[ '1.am a employer with. --'3 4, ❑I am a general contractor and 1 6. EJ Now construction employees(full and/or parE time)* have nod the sub-contractors 2.El am.a solo proprietor or partner listed on the attached sheet.� 7• emodeling ship and'haveno.employees These sub-contractors have 8. []Demolition working forme in any capacity. workers' comp,insurance, 9. ❑Building addition [No workers'comp.insurance 5. [] We are a corporation and its 10.❑Electricalrepairs or additions required.] officers have exercised.their 3,[i I am a homeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions myself.[No workers' comp. c.152,§I(4),andwehaveno UPRoofrepairs insurancere ired. employees.[No workers' ] Un Other comp.insurance required.] Any applicantthat checks box41 must also fill outthe section below showingtheir workers'compensation policy information. i Horneowners who submit this affidavit indlcating they o'ra doing allworlt and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheekthis box must attached an gdditional sheet showing the name of the sub-contractors and their workers'comp,policy information. f am are employer that is p�ovkiing workers'eomquensation insurance for my employees Below is thevolley and job site infarmallon. Insurance Company Name% fie,,7`z-r-.- y Policy#or Self~ins,Lic.#: Expiration Data: 7"" J/ �y Soli Site Address: F f'b c l— City/State/tip: V 3 ve-,., me Attach a copy oftlie workers'compensation-polzcy declaration page(showing the policy number and expiration date). ydilure to secure coverago.as requnedumer Seotion 25A ofMGL o. 152 can lead to the imposition,of criminal penalties of a Imo up to$1,500.00 and/or one=year imprisonment,as well as civil.penalties in the form of a STOP WORD ORDER.and a fine of up to$250.00 a day against the violator. 130 advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do raereby eerti under the alias and enalties ofverjury treat tree information.provided above is true and correct. Si afore: Data: c�T c�•©'r/ 'hone#• � '.r -1�� Official use only. Do not write in this area,lobe completed by city or town official: City or Town, PermMicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: x M®NWE) TH OF M SETTS .-i ,., gQ�11`iC► 7F ISSUES THE F(7l LpWIIWG t 10E'NSE AS, AI ftECISTER>EG MAs� Cr ,; LECTRIG1IAN . JOSEPH C G I ACCHETTf1 32 L©NGMMOW Rd CNELMSF0RD MA 01824-2o45 20426;:.A . 0 /3 /1�, 44727' y A