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Home My WebLink AboutWiring Permit - Permits #12328 - 790 DALE STREET 5/2/2014 z YJ Date..........................J ..................... N°RTHga TOWN OF NORTH AIVDOVER WIRING ° p PERMIT FOR I 88ACHUS This certifies that ...........................�f ermission to p hasp ,....... � t ...... . ... Wiring in the building of ......... 9 , North Andover, _ a . a . t ... e y e A czo Fee ................. , 7 = Check# --- --- 4 Commonwealth of Massachusetts Official Use Only Irk of Permit No. l f Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMit 12.00 (PLEASE PRINT IN INK OR TYPEALL INFORMATION) Date: 5/02/2 14 City or Town of: N'w`rR`I`1 AND(..)VER To Me 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) 790 D aie; Street Owner or Tenant Carl & Hopi Wighardt Telephone No. Owner's Address Sarne Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Home 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: Repair de'l'ective service n,iea'ter installation arid generator feeder rnain breaker. Coni lesion of thefiolloiving table may be waived by the Inspector of Wires. No, of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No. of Total Transformers KVA No. of Lighting Outlets No.of Hot Tubs Generators KVA No, of Lighting Fixtures Swimming Pool rnd.bove In-rnd. Batte Units o. o Unitsmeri cy ighting M 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 I.Number Tons KW No. of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Beating KW Local ❑ Municipal ❑ Other, Connection No. of Dryers 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 E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail i fdesired,,or as required by the Inspector of Wires. 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 x❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: .[ (When required by municipal policy.) Work to Start: 05/05/ 014 Inspections to be requested in accordance with MEC Rule 1.0, and upon completion. I certify, under the pains and penalties of perjury, that the inforination on this a])plic f#ion is true and complete. FIRM NAME: Steven A.Callahan Electrical Services LIC.NO.: 12676A Licensee: Steven A. Callahan Signature -" LIC.NO.: (If applicable, enter "exempt"in the license number line.) Bus. Tel.No.: 978.457,6843 Address: 25 Temple Street, Haverhill, MA 01832 Alt.Tel.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 ❑ owtier's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The C.'ommonwealth oJ'Massachusetts 6 Via; 1 wr Department of Industrial Accidents w 4 Office of Investigations i 600 Washington Street Boston MA 02111 wtivw.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): St,evewi A. Call.than Electrical So ryices Address: 25 Temple Street City/State/Zip: Haverhill, MA 01832 Phone#: (978)457-6843 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with Full-Time 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 5. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. M Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' [No workers' comp, insurance comp.insurance. q• ❑ Building addition required.] 5. We are a corporation and its 10.® Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself No workers' com right of exemption per MGL y [ p• 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, #Contractors 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. I am an employer that is providing ivorlrers'compensation itzsur(uace for my eny)loyees. Below is the policy and job site information. Insurance Company Name: 'The Hartford Policy#or Self-ins.Lic.#: #83 WSC NF 3325 Expiration Date: 02/16/2015 Job Site Address: 90 Dale Street City/State/Zip: N. Ancloyer, MA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required 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-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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif, r the pains penalties of perjury that the information provided above is true and correct. Si natu ,: .,. Steven A. Callahan Date: Phone#: 978.457.6843 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#: COMMONWEALTH \ � � : §r . , . . /H dSETTS y. .\ ��NA�f/ /mA��f� BOARD \ ^ ELtCTRICIANS » ? ISSUES THE .FOLLOWING LICENSE ,A\\ REGISTERED MASTER ELECTRIC!«¢ d«V .STEVEN A CALLAHAN y . ^ �2 : \» \ ^ 25 TEMPLE \}R/[T . � � �ƒ . � , � \ , . . \ \) \HAVERHIIA. y MA 01/32-5412 12676 \��07 /1 7223