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Home My WebLink AboutWiring Permit - Permits #12557-1 - 242 DALE STREET 8/4/2015 Date...... ....... ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ACHU This certifies that ........ 6 ') ......... ..... .... .... .................................... 4 has permission to perform ... ......... ............................... wiring in the building of....... ........ ............................................... ............... at ......... ............11...............I.......... ...........................................North,Andover,Mass. ................................. .... ..............Lic. No. ........... -'J - �' I",� Fee.. .... . t......b ELECTRICAL INSPECTOR Check# 4i 74 J Print F, orm--] Official Use Only 2,,P.,t..t 3i"Serviced Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-I/o7] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( EC) 527 CMR 12.00 T,ORMA TION) Date: S1 (PLEASE PRINT IN INK OR TYPE ALL IN City or Town of: To the Inspector oj'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 buil: permit? Yes No (Check Appropriate Box) v Utility Authorization No. Purpose of Building Existing Service Amps Volts Overhead 0 Undgrd❑ No.of Meters New Service Amps Volts Overhead [J UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table ma be waived by the Inspector of TVires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting rnd. rnd. Batte No.of Luminaires Swimming Pool EJ n r g g y 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 Tons No.of Waste Disposers Heat7u—mp Number I Tons KW,---. No.of Self-Contained Totals:I--—------- Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Mun'cipal Connection 0 Other No.of Dryers Heating Appliances KW Security Systems:1 No.of Devices or Equivalent No.of—Water No.of 0.of Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Device or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector,of ff"ires. 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 21 . BOND R OTHER FI (Specify:) Icei,lify,uiidertliepaiiistindpetiallie.vofperjitiy,tliat the iiiforitiatio oith' ap c ti is true and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature— LIC.NO.: 14963 (Ifapplicable,enter"exempt"in the license number line) Bus.Tel.No.-978-682-6262 Address: -8713ELMONT ST.NORTH ANDOVER, MA 01845 Alt.Tel.No.:978-375-5734 *Per M.G.L.c. 147,s.57-6 1,security work requires Department of Public Safety'IS"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)F1 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ow, e....... Q—C TOWN OF NORTH ANDOVER PE FOR WIRING ,88ACHU Thiscertifies that .. ..... ......... ............. ... ................................................................ has permission to erfo ...................... ................... wiringin the buildi of......... ....... ............................................................. at -s NQrth Andover,Mass. .......... . .....I................... . .... llf P-' . . .......... Fee,Lf ...............Lic.No. ................. a eu ELECTRICAL INSPECTOR Check# ]L evo 2 Print Form -- �omrnoivaeaLl�o� as�acfzu felts OfficialUse Only - Permit No. u . -~. Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( C),527 CMR 12.00 (PLEASE, PRINT IN INK OR TYPE ALLINFORMATION) Date: 7 City or Town of: _ /\J;)�27/ 1fA1tY6c6e 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 (Check Appropriate Box) Purpose of Building Utility uthorization No. Existing Service Amps Yolts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts verhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electr' a rk: om letion a the ollowin table may beivaivedbythe.Inspectorof TVires. No.of Recessed Luminaires No.of Ceil.-S p.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets of Hot Tub Generators KVA No.of Luminaires Swi4ning Po 1 Above In- ❑ o.o Emergency Lighting rnd, rnd. Battery Units No.of Receptacle Outlets No,o Oi urners FIRE ALARMS No.of Zones No.of Switches Na f Gas Burners No.of Detection and Initiating Devices No.of Ranges o,of Air Cond. Total No.of Devices Tons g No.of Waste Disposers Heat PumpNu-,__er Tons KW No.of Self-Contained d Total ..-_ _......_.,.-_-----...._.................__._.. Detection/Alerting Devices / No.of Dishwashers Space/Area lVating KW Local El Municipal ❑ Other Connection No.of Dryers Heating ApIliances KW Security Systems: No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters XW Sin Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of YVires. 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 F BOND ❑ OTHER ❑ (Specify:) 1 certify,under the pains and penalties of pcu lity,that the inforinatiau oil this p lice t is true and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature _ - LIC.NO.: 14963 (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.:978-682-6262 Address: 87 BELMONT ST, NORTH ANDOVER, MA 01845 Alt.Tel.No.:978-375-5734 *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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. FPERMIT.FEE. $ ~ The Commonwealth ?fMassachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston MA 02114-2017 wwminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lelsibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address:87 BELMONT ST City/State/Zip:NORTH ANDOVER, MA 01845 Phone#:978-682-6262 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with 8 employees (full and/ 5. ❑Retail or part-time).` 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. F1 Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity: [No workers' comp. insurance required] $• ❑Hon-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 11•� Health Care with no employees. [No workers' comp. insurance req.] 12 ther ELECTRICAL CONTACTING *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I arrr an employer that is providing workers'comperasatiort irrsr[rance for my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy#or Self-ins. Lic. # 9353694 Expiration Date:MARCH 1, 2015 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 ins e coy rage verification. I do hereby certify, under the air an r hies of perjury that the information provided a ove is r•ue and correct. Signature: Date: Z/& 1 � 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.Licensing Board 5, Selectmen's Office 6.Other Contact Person: Phone#: wnaw.mass.gov/dia .1 : ` COMMOYVWEALTH OF MA,SSAGHUSETTS:._ . BE1Af O Ut E.IECTRICIANS ISSUES THE..-FOLLOWING LICENSE`AS A; } REG I S,'ERED MASTER. ELECTR VC I AN _ �a KRISTO�PHER D HA GAR � 1' ! j h. 631 RIVERSIDE AVF IW i lU APT 2 � i HAyERHILL MA 01830 �773 E Q7/�1/1 32655 ®. n v