The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Permits #13229 - 44 FURBER AVENUE 4/14/2015 r Date. ............ I o�`4.0AT" 'tio TOWN OF NORTH ANDOVER c p PERMIT FOR WIRING ej j BACHU55 f:f ...................... certifies that t �. ...............:........ �• ............................. This cerU •••s ,� � � J fd . . .......................... ssion to perform` `r.• N ... .. has permr 4 �ry�' l ..................................... Wing in the building of r t f n v , .` , >North A do e' e e 9 9 .. ....................... e iat . A ............... y rELECTRICAL INSPECTO Fee. ..... Lic.No. ... .. Check — — Only Commonwealth of Massachusetts Official Use Permit No Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) -------------- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NIEC),527 CMR 12.00 (PLEASE.PRINT IN INK OR TYPE ALL INFORMA TION) Date: ...... 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) Owner or Tenant—70�Y�. 444'rVo4z Telephone No. Owner's Address A'ev�c Is this permit in conjunction with a building permit? Yes No F1 (Check Appropriate Box) Purpose of Building PUtility Authorization No. Existing Service Amps Volts OverheadF] UndgrdF] 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 following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA N 0.of Lunijil, o.of Luminaire,Outlets No.of Hot Tubs Generators KVA N 0 of Luminaires Above o In- Fi No.of Emergency Lig tmg o.No. fLuminaires Swimming Pool grnd. grnd. Battery Units T No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices. No.of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices al No.of Self-Contained Heat Pump I.NM,!Aber I Tons IOW No. of Waste Disposers I I Totals: I ..................... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Municipal F] Other Connection No.of Dryers Heating Appliances 11(w Security Systems:* No.of Devices or Equivalent No. of Water No.of No.of Data W' ' Heaters KW Signs Ballasts — No.or'1 : Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total UP Telecommunications Wiring: No.of Devices or E quivalent OTHER: Attach additional detail if desired,or as reqidred 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, cHEci<ONE: INSURANCE F1 BOND El OTHER F1 (Specify:) I certify, under th e pains an dpenallies o p eiyujy,th atElie inforniation on this application is true an d complete. FIRM NAME LIC.NO.: Licensee: < CL elk- Signature LTC.NO.: (If applicable,entei"exempt"in the license number line) Bus.Tel.No.- Address: Alt.Tel.No.• *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lio.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)[j owner F1 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massach usetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 WWW.n1(1ss.g0V1(1i(1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibl Name (Business/Organization/Individual): Address: City/State/Zip: �&4�e.e_ Phone#: 5rcv q Are you an employer?Check the appropriate box: Type of project(required): I.[]I am a employer with employees(Rill and/or part-time).* 7. F1 New construction 2.F]I am a sole proprietor or partnership and have no employees working for me in 8. n Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F]I am a homeowner doing all work myself.[No workers'comp.insurance required,]t 4.F]I am a homeowner and will be hiring contractors I 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.E]Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5f]1.am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. Iaiiiaiieniployet•tliatis providing ivoi-l(ei-sleoitipei,is(itioniiisiti-aticefoi,ittj?employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. 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 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. I do hereby certify under thepains andp9i7l ies of perjury that the inforinationprovided above is true and correct. Signature: e��L Date: Phone Zt, Official use only. Do not write in this area,to be completed by city or to)Pn official City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:- Phone#: I Commonwealth ofA4as Division of Registrati usetts, Board of Electric �..,� RYAN M E � 45 ADA r . u� > . L'AWREN 9 }' Master Efec �T 07/31/2016 License No. Explration Date. 008835 Serial No.