The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Permits #12981-1 - 133 DALE STREET 12/23/2015 Date... �.. . .�. ...... of tNoRrh,� oar:. °09 TOWN OF NORTH ANDOVER * .0 . * PERMIT FOR WIRING ,88ACNUs�� This certifies that ..,.,. ° � ..�....................� ...... .................... has permission to perform .., .`.a F i .. e ��a ......... .................................. wiring in the building of......;: ......................... at �2 €6 ItTorth Andover,Mass. Fee... .. ..............Lic. No, 1ve.. ...c �......... -:... — ELECTRICAL INSPECTOR Check# I Commonwealth of Massachusetts Us,Only Permit No. Department of Fire Services occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblanlc) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEA SE PPdWT IN INK OR TYP E-4 LL INFORMATION) Date: '[)ec, L',"'), 5 -- 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 Q t,,A !E Telep hone No.!] r. Owner's Address Is this permit in'conjunction with a building permit? Yes ❑ No F] (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service— Amps volts Overhead [] Undgrd[] No.of Meters New Service Amps Volts Overhead[-1 UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: C)1,4 E. t"I R Completion of the fallowing table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cefl.-Susp.(Paddle)Fans No.of Total Transformers le-VA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above [i In- ❑ f Elm ergency Lighting No.of Luminaires Swimming Pool grnd. grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners elµ FIRE ALARMS iNo. of Zones of Detection and No.of Switches No.of Gas Burners No.Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW.1 No.of Self-Contained Totals: iDetection/Alerting Devices Municipal F] other No.of Dishwashers Space/Area Heating KW Local[-1 Connection N ur o.ity of Systems:* No. of Dryers Heating Appliances KW Sec Devices or.Equivalent No.of Water KW` No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Wiring: No.Hydromassage Bathtubs No.of Motors Total HP Tel No.of Devicesecommunications or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Ores. 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 [I BOND n OTHER F1 (Specify:) I certify, under the pains and penalties ofpeijury,that the information on this application is true and complete. FIRM NAME: LTC.NO.: Licensee: V� Signature 7, LTC.NO.: rz, (Vapplicable,enter "exempt"in the license number line) V Bus.Tel. Address: I two C ","V:E."IJAC ,-61,q ml 865e� Alt.Tel.No.: 6,2.2.1 *Per M.G.L c. 147,s.57-61,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)0 owner El owner's agent. Owner/Agent Signature Telephone No. PERMITFEE.- $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 5� �~ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizati6n/Individual): I lbd�t� b� l 1'"° Address: is 2 11 "IN .. ,. ) City/State/Zip: JN .0 a I CZ8 Phone#: 8 a°° Li C.0 2 .. Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 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. # ? ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LFJ 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' 13.❑ Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Dontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that isproviding uvorkers'compensation insurance for my employees. Below is thepolicy and job site aformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: :)b Site Address: I F53 =. k1c)QU-4 At,MOVER City/State/Zip: fVAA Ueln5 Atach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 P up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify sander the pains and penalties of per;jury that the information provided above is trite and correct. icnature: „� �� „. , � �� > Date: 1° " w r� ,. 9 ) (- Official use only. Do not write in this area,to be completed by city or totipn official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,.COMMONWEALTH OF MASSACHUSETTS 80f1 D6F ' I�SSUES 'THE,FpLLOWING t=.IGENSE AS ;A }��_ � R�GrTRt D MASTER ELECTRd C IAN TIMOTHY G WYNNE E 1 106 BROApWAY ; FIAU. RH I LL MA 01832-1405 2 4oz: A... 0713.E/16 5oo67