The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Permits #13246-1 - 776 DALE STREET 4/5/2016 Date............................................. �� ,NoarH�tioo� TOWN OF NORTH ANDOVER . * PERMIT FOR WIRING BACHUg6 This certifies that .........'� ��..° '.?..a...... �� . �� has permission to perform ........... .....`. '. .'1 �. ....:. ....... ®..... ..�.. wiring in the building_of. 1,'.e:1., ? is............. i?, �6 �� at ) 0 !d 1 7 ' ................... ............................... ,...:.... �..............::.'./.... ................... .............�:.;.....,......., North Andover Mass. E � Fee . �.... Lic.No � ..`% ..,! r Check# �! �` ELECTRICAL INSPECTOR j 00// Print Form l�o//��nz wnwealU of Mamac4wetb Official Use Only 2 epartownt of Jim Servicee Permit No. Occupancy and Fee Checked y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1107] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Gf�g 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) :2 241, ✓ +'Sr' Owner or Tenant G'd1✓3�,t /,��°,vtA Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑e (Check Appropriate Box) Purpose of Building 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: �jUSjyy L/dy7--/� nw Completion of the folloiving table inay be waived by the Inspector of Wires. 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 No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. BatteKy 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 Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Other Connection El 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 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 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 ❑✓ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this np is tion e 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 PERMIT FEE. S '- SignaturetoreTelephone No. "s The Commonwealth of Massachusetts Department of Industrial Accidents h Office of Investigations t 600 Washington Street ;ALL Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/hrdividual): I DAVID ELECTRICAL CONTRACTING LLC Address: 187 BELMONT ST City/State/Zip: NORTH ANDOVER,MA.01845 Phone#: 978 682 6262 Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 4 _ 4. El I am a general contractor and 1 6. ®New construction employees(full and/or part-time).* have hired the sub-contractors 2.Q I am a sole proprietor or partner- listed on the attached sheet.+ 7. n Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'comp. insurance. 9. Building addition [No workers' camp.insurance 5. We are a corporation and its required.] officers have exercised their 10.2Electrical repairs or additions 3. I atn a horneowner doing all work right of exemption per MGL I I.®Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.[n Roof repairs insurance required.] employees.[No workers' comp, insurance required.] 13.[ Other *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 their workers'comp.policy information. I arrr art employer that is providing workers'eorrtperrsation insurance far trty employees. Below is the policy and job site information. Insurance Company Name: FEDERATED INSURANCE Policy#or Self-ins.Lic.#; Expiration Date: -- 9353694 p• / Job Site Address: 6 ° City/State/Zip: N ' 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 certify under the pai s t Vrp, t e of perjury that the infortttatiort provided ahoy is tr re arul correct. Signature: Phone#: 978 682-6262 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#: