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Home My WebLink AboutWiring Permit - Permits #13004-01 - 158 DALE STREET 1/7/2016 Date ........................ Of NORTH 9y o ' TOWN OF NORTH ANDOVER ow PERMIT FOR WIRING ss�cmus�t This certifies that has e P rmission to perform q ......................® wiring in the building of......... """ ats ewl ....... .. .................... ....... t f Nor(l�Andover,Mass. Fee An .....Lie.No. •• ....... ( d ................................. Check# �, Et Bcrxicnc INSPECTOR Commonwealth of Massachusetts osftmiet Uoa only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ,527 CMR 12.00 (PLEASE PRINT W INK OR TYPE .XFOR MATIOII9 3�a�e: � ;�l/�s City or Town of: 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 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑.Building PerWt Purpose of Building Utility Authorization No. Existing Service Amps / molts Overhead ® Undgrd❑ No.of Meters New„fervice Amps / Volts Overhead❑ Undgrd C3 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Co letion of the following table may be waived by the Ins ector a Wires. f Total No.of Recessed Fixtures No.of Ce"usp.()Paddle)Fans Transformers TK'VA No.of Lighting Outlets No.of Hot Tubs Generators R.VA No.of Lighting Fiaturee ��' Swimming Pont rnd.e n�d. D �Batle V�enc3' � g No.of Receptacle Outlets No.of Oft Burners AL S No.of Zones No.of Switches ; No.of Gas Burners o.Initiate De ices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers er „tins- o.o e - o-ntaine Totals: ""- " Detection/Alerthm Devices No.of Dishwashers Space/Area Heating IOW Local Connection ® Other Heating Appliances Rylt Security ystems: No.of Dryers No.of Devices or Equivalent- o.Of ater o.-07 NO.Of Data Wiring: Heaters KW Signs Ballasts No.of Devices or E uivalent motors Tot H a ecomuun ca ors Wiring. ofNo.Hydromassage Bathtubs No.of Devices or E uivaleut OTHER: 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 V BOND ❑ OTHER ® (Specify.) (Expiration Date) Estimated Value of Electrical Work:` l�' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of pedu►y,that the information on this application is true and complete:Current Insurance cenYfleate must be on flk to our 0,0*e af�idav/ti arssst aahv heflle eat width each appReatdvA FIRMN �.L //L--/z �: t� t �4�0 �5 G e c' LTC.NO.: ,0675 Licensee: /i i� fr.� �� Signature LIC.NO.: _ erapplicable,enter ';�i"in t e license number li e.) Bus.Tel.No.:., J°'J Address: if/ A` 4 2 S Alt.Tel.No: - OWNEIx'S S E WAIVER: T nm 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 a ent. Own tore nt pF ITFXEO. Signature Telephone No. The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A rmation Please Print IZ,e ibly 4� Name(Business/Organization/Individual): �&1,19 Address: City/State/Zip: /f � n-el- IW4 anIs- Phone#: A,re you an employer?Check the appropriate box: Type of project(required): 1 l am a employer with 0— 4. E] I am a general contractor and 1 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. E]Building addition [No workers' comp.insurance comp.insurance.1 1011 Electrical repairs or additions required.] 5. E] We are a corporation and its 3.0 1 am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.[]Roof repairs insurance required.]f c. 152,§1(4),and we have no 13.[] Other employees. [No workers' comp.insurance required.] *Any applicant that checks box Mmust 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 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 workers'compensation insurance for any employees. Belo.w is the policy and job site information. I Insurance Company Name:./4�196w Policy#or Self-ins.Lic.#: 0 Expiration Date: 7 1" / Job Site Address: /1, ", -A, J City/State/Zip: 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. fication. Ido hereby certify under the ai:;nd Id, ofperjury that the information above is true and correct. .the and�enaj e� /7 Date: SigLiature: A 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#: STATE OF NEW HAMPSHIRE ELECTRICIANS BOARD NAME: MICHAEL D SMALL 13484 M EXPIRES: 11/30/2018