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Home My WebLink AboutWiring Permit - Permits #12786-1 - 240 DALE STREET 10/20/2015 i 4�f Date..........�............ .s............. OF�.►ORT/.�4ti TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING ��88ACHU9�4•l This certifies that .. .:. ••• pp ' has permission to perform •• •• ..............• •••.......... i wiring in the building of.......� C i I � North Andover,Mass. at ............... ........................... 5 , cto �5 Fee. Lic.Nod ....... ....................................................... ELECTRICAL INSPECTOR Check# -_ — Commonwealth of Massachusetts Official Use Only Department it Services vices Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [R.ev. 11071 (leave blank 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 INMK OR TYPE ALL INFORMATION) Date: /p -z' /-6— 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) --- / 2 Owner or Tenant 1= Telephone No. Owner's Address Is this permit in conjunction wit building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 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 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 No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ W-0707Emergency Lighting rnd. grnd. 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 Initiating Devices No.of Ranges No,of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: "'" ' ' ""'��"'"n "��"'W....."".. Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW SecN eto.o Devices or Equivalent No. of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent_-. No.H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or E uivalenf 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 ❑ BOND ❑ OTHER ❑ (Specify:) Icertify, under thepains andpenallies ofpel'uf ,that the information on this application is true and complete. FIRM NAME: LTC.NO.: �"G Licensee: Signature, - -'` LTC.NO.: (If applicable,enter "exetnpt"in the license nu er ' e.) Bus.Tel.No.• ` J� Address: Alt.TeI.No.• 'Per M.G. c. 147,S. -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 PERMIT FEE: Signature Telephone No. The Commonwealth of Massachusetts . :. ' Department of fnatustriar.Aecidents M _ r X Congress Street,Suite 100 _ Boston,MA 02114 2017 q�r www.mass.gov/dia woi:kers'Compensation insurance Affidavit:Builders/Contractors/E1ectricians/1'l1m ers. TOM,FILED WITH THE PERMITTING A 1JTHORITY. Please Print Le 'bl A i'licant Information Name(Business/Organization/tndividual) Address: City/State/Zip: Type of project(xequired): Are you an eoyer?Cheec the appropriate box: mpl to full and/or part-time,).* 7. ❑Ne*'donstriiction l.Q 1 am a em ployer withem P yces( 2.❑1 am a sole proprietor or partnership and have no employees working for mein $. Remo deliiig any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3•❑lam a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4,❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 11.❑Electrica ensure that all contractors either have workers'compensation insurance or are sole l repav:s or'additions proprietors with no employees.ensure Plumbing repairs or additions 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 11 Ro6f rep airs These sub-contractors have employees and have workers'comp.insurance.$ 1<1 Other 6.Q We aro a corporation and its,officers have exercised their right of'exemption per MGL c. 152,§l(4),and*.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. Homeowners who chpolo b'k'affidavit indicating they are doing all work andthen 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(hose entities have employees. If the sub contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. •below is the policy and)oh site information. Insurance Company Name: Expiration Date' Policy#or S elf-ins.Lie.#: �� -� City/State/Zip- Job Site Address: Attach a copy of the workers' coxupensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL e.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 f 's atement maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. X do hereby certify e p andpen ti of pezjuly that the information provided above is true and correct. Date: Si a e Phone ih - zcial 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person; CE' MON1IUEALTH CF'MASSACHOSE "° , BOAit1.,OF. »� .�017!j!YhtjM Et`ks ;—erto r-� �;. h � 03 U VOW. Vow r e