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HomeMy WebLinkAboutWiring Permit - Permits #12570-1 - 11 DANA STREET 8/10/2015 i . I Date ��.� �. .............. �NORrN, ?.•'"�:':�•�°o� TOWN OF NORTH ANDOVER h m a PERMIT FOR WIRING ,88�CHUg�t� ! This certifies thatz_ " _� ................... . ...... ....... ... .......................................... o has permission to perform ..... \ � �C' e �� ......................................................* ............................... wirin in the building of.. � ................................. .:......... .. . ....... o Andover,Mass. Fee..... : �... .....Lic.No ,�„ ELECTRICAL IN ECTOR ICheck# Commonwealth of Massachusetts Official Use Only 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 WC),527 CMR 12.00 (PLEASE PRINT 1INK OR TYPE ALL RVFOMIM TION) Date: IS City or Town of: NORTH ANDOVEi R 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) 7dw Q 31' Owner or Tenant FraAk P-0 i"i Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes [9" No F1 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service_ Amps Volts Overhead ❑ UndgrdF] No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity ,A Ce qJCV) T�0 Location and Nature of Proposed Electrical Work: ll L' Completion of the followingtable may be waived by the Inspector of Wires. No.o No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total formers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires C7 Swimming Pool Above Ei In- ❑ lVo—.—oTE—mergency Lig ting grnd. grnd. Battery Units No.of Receptacle Outlets a No.of Oil Burners FIRE ALARMS I No. of Zones of Detection an No. of Switches No.of Gas]Burners No. Initiating Devices No. of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No. of Waste Dis Heat Pump .,.......... bex. �.Tqp.s..........I.ICW.......... Co.of Self-Contained posers Totals: I Number"I I Detection/Alerting Devices No.of Dishwashers Space/Area Heating K W Local❑0 Municipal n Other Connection No. of Dryers Heating Appliances KW Security Systems:!' No.of Devices or Equivalent No.of Water IOW No.of No. of Data Wiring: Heaters IT/. ........ Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent 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 m BOND 0 OTHER El (Specify:) Icertify, under the pai s penalties qfpqrJuiy,that the in orinatioy on this application is true and complete. plete. LIC.NO.- 2- FIRM NAME: "k 1 �W-,y 1 C-r, 5 - —L-1 2- &L�—� LTC.NO.: Licensee: Signature (If applicable, tr "exe t'in the license number line) Bus.Tel.No. Address: J , I A0 41 1072- S�Jeb, -4J!l Q ?07 9 Alt.Tel,No.: *Per M.G.L c. 147,s.57-61,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)[I owner El owner's ag�ent- Owner/Agent Signature Telephone No. PERMIT FEE: $ 1 9 -❑ 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 Chapter 240 of the Acts of2010 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 extending through August 15,2012. ❑ Rule R—Permit/Date Closed: * *Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass[N Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass IN V Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL,INSPECTION: Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 1 The Commonwealth of Massachusetts Department of IndustrialAccidents M •�- _ 1 Congress Sheet, Suite.100 02.114 2017 4 Boston,MA.^ www-mass.gov/dia OEM Sy�v wog:lrers'CompensationInsurranceAffidavit:Suildexs/Contractors/Electricians/Plum exs. TO BE MED WITH THE PEgMMTTING.A-UTHOPIT,Y. Please Print Le bl A '•licant Information -C r v `C 5 Name(Business//Organizationllndividual): G �cQ P(� C r CCA Address: Po t City/State/Zip: GI �P h^ �Cl d © `7 c( Phone A.ro yo an employer?Checlt the appropriate box: Type of project(required): em to ees full and/or part time). 1. Neiv d6ristriictlon 1. I am a employer with___ ____ P y 2Q I am a sole proprietor or partnership and have no employees working forme in $. 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. I will 11(�Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole bin airs Or additions proprietors with no erriployeas. STD g repairs 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F!Ko6f rep air6 These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.Q 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.] x Any applicant that check§box#1 must also fill out the seetionbelow showing their workers'compensation policy information. i Homeowners who subrrut•this affidavit indicating they are doing all work and then hire outside contractors must submit anew.affidavit indicating such. $Contractors that check this box must attache d'an additional sheet showing the name of the sub-contractors and state whether of not(hose entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is Providing workers'compensation insurance for my employees. Pelow is the porky and)oh site information. Insurance Company Name: Expiration Datc' Policy#or Self ins.Lic.#: . �/� _City/State/Zip: Job Site Address: � !�ql� Attach a copy of the WOrkexs' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e.152,§25A is a criminal violation punishable by a firle up to$1,500.00 and/or one-year imprisonment,as well as civil penaltiesSnvOesgations of the DIA for insuranceER and a fine of up to 00 a day against the violator.A copy of this statement may be forwarded to the ffi e coverage verification. X do hereby certi under tliepains andpenalties ofper Date: jury that the information provided is true and correct. Si ature: Z Phone#: official use only. Do not write in this area,to he completed by city or town official. Permit/License City or Town: # Issuing Authority(circle one): 3.City/Town Clerk4.Electrical Inspector 5.Plumbing Inspector 1.Board of Ifealth 2.Building)Department 6.Other Phone#: Contact Person: OMMRkWkkL H OF Mkk§kCHUSETTS / ; § BOARD OF \\\\\ \ :ELSCTRICIAN.S \\ \( \ \S U S\H \L 0}N f / E T/EMASTER\(L G R 7N \ \ . /0/R F\CHANDLER \ \ \ �� \ /\u V } . /A/M H Q\7 \ . . : . »wc \7 2\653470 \ ©2 � , .