The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Permits #12783 - 521 DALE STREET 10/2/2014 Date... ..... ......�. o°NORrH�tio TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING �88ACHU`�� i a$ .................................. This certifies that ............ r � _ ................ has permission to perform ................... 6........ m ye wiring in the building o ................I...... North Andover,Mass. <at .. .. .., Fee::.............. ELECTRICAL INSPECTOR �Lic Check# nn// ��//nq Print For Commonwealth of/i'/aMac4adett� Official Use Only 2epartment o f Jire Seruice6 Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave biank) APPLICATIONI 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: 10/2/14 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)521 dale street Owner or Tenant david sikora Telephone No. 9786826376 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building dwelling Utility Authorization No. Existing Service 200 Amps / Volts Overhead❑ Undgrd❑ No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: wire new fireplace receptacle with afci and disconnect S Completion of die following table may be waived by the Inspector of Wires. C No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA t� j No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig mg 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 Initiating Devices �} No.of Ranges No.of Air Cond. Total No.of Alerting Devices --e Tons No.of Waste Disposers Heat Pump I Number I Tons KW No.o Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kam, Security Systems:* No.of Devices or Equivalent No.of Water K`,t, No.of No.of Data Wiring: 4� Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent OTHER: Attach additional detail if desired,or•as required by the Inspector of Wires. Estimated Value of Electrical Work: 400 (When required by municipal policy.) Work to Start:10/2/14 Inspections to be requested in accordance with EC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the p orm mce of electrical work may issue unless the licensee provides proof of liability insurance including"completed operatio coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited prW ofme to the permit issuing office. CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (S e If I certify,under thepains andpenalties of petjuty,that the ittfot- tat qapplication is true and complete. FIRM NAME: lance macinnis electirc LIC.NO.•21217a Licensee: lance macinnis Signatu LIC.NO.: (If applicable,enter"exempt"in tite license number line) Bus.Tel.No.:5087260802 Address: 12 locust street middleton ma 01949 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Departmen 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 Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 gym` www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print I,eIibly Name (Business/Organization/Individual): lance macinnis electric Address: 12 locust street City/State/Zip: middletan ma 01944 _ phone #: 5087260802 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 1 4. _ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised their 10. . Electrical repairs or additions 3.EJ I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. Roof repairs insurance required.] t employees. [No workers' 1311 Other 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 their workers'comp.policy information. I am an employer that is providing ivot leers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: the hartford Policy#or Self-ins. Lic. 1 V37K Expiration Date: 1/1/15 Job Site Address: 521 dale street City/State/Zip: .attach a copy of the workers' c pensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as re red under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one ar 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 i violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the°DIA for 'n urance coverage verification. Ido hereby cer fy t let l"fepains andpenalties ofperjury that the information provided abovo is t'ue and correct. Signature: Date: Phone#: Official 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 Contact Person: Phone#: