HomeMy WebLinkAboutWiring Permit - Permits #13124 - 311 DALE STREET 2/24/2015 Date....................q....
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TOWN OF NORTH ANDOVER
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Fee.... Lic. No. �. .
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Commonwealth of Massachusetts Official Use Only
Permit No. �3� 1,�2
Department of Fire Services
Occupancy and Fee Chocked
W BOARD OF FIRE PREVENTION REGULATIONS .[Rev. i/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL MOR W TION) Date: d,d V-8"
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned givo 7wticc of his or her intention to perform the electrical work described below.
Location(Street& umber), Vq I C S7
Owner or Tenant Zzo?,L;,-rA�w!i.°I Telephone No.
Owner's Address
Is this permit in conji7tion with a building permit? Yes ❑ No ❑ (Cheel(Appropriate]Box)
Purpose of Building. 14")F C Utility Authorization No.
Existing Servlce,,7 6 Amps )d4,,) 11�40, Volts Overhead 0 Undgrd n No.of Meters
New Service — Amps Volts OverheadF1 Undgrd [I No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ,��Iws-,7pqz,c dvrw S"�,C4�
Completion of the following table may be waived by the Inspector of Wires.
No.of Total
No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No. of Hot Tubs Generators KVA
No.of Luminaires swimming pool Above [j In- ❑ N-650—ffi mergency Lighting
grnfl. grnd. Batter v Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS iNo. 6f Zones
No. of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No. of Ranges No.of Air Con d. Total No.of Alerting Devices
Tons
No. of Waste Disposers Heat Pump ........... No.of Self-Contained
Totals: I Detection/Alerting Devices
--I
No.of Dishwashers Space/Area Heating KW Local F1 Municipal 0 Other Connection
...........
No. of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No. of Water Na.of No.of Data Wirin
Heaters KW Signs Ballasts . No.of Deg:
vices oyEguivalent_
No.Hydromassage Bathtubs No.of Motors Total lip Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of If7res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: q "t S" Inspections to be requested hi 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 a— BOND 0 OTHER F] (Specify:)
leepilry, iin(lei-ilieptiiiisandpenaltiesofp jury,thatthei ormation on this application is true and coin e eij pl te.
FIRMNAME� kfe) 'IS' /
L); LTC.NO.:
w.
U18iirria"ture LTC NO
Licensee: 6t
(Ifapp pt in ' ine) 110 " —Bus.Tel. o.:
Address te4t S '
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)[:1 owner [I owner's agent.
Owner/Agent
Signature Telephone No. PERMITFEE- $
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_. The Commonweal&ofHassachusetts
Department ofIndustrigl AccMiks
Office of Ifivestigatroz's
660 Washington Street
Roston,.MA 02111
vww.rnass gov1d a
workers, Compensation fusuran.ceAffidavit:BuilclersfColntractor)Electrlclans),Pliiinber,m
A-P-911cant-Worrnation. Please Print Le x�bZy
a]zl o(Business/Oxgani'zationLhidivzdual . � ° "
A
Address: .. 4 .
City/Statelizip: L '". :�� '" Phony#:
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑Z am,a general contractor and 1 6. []New construction
'Pmployees(full and/or pact time).* have hired the sub-contractors
2: j am a sole proprietor or patn.er listed on the attached sheet.x 7• ��eanodelYng
ship andlavo no.omployeos These subcontractors have 8. E]Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
reo workers' eom insurance 5. ❑ W e are a corporaAon and its
quired.] p officers have exercised.their 1 . electrical repairs or additions
3.[l x am a homeowner Going all work right of exemption per MGL 11.❑Plumbingxepairs or additions
myself.[No workers'camp. c. 152,§1(4),andwehaveno 12.Q Roofrapairs
insuxancerequixed.]t employees.[No workers' 13.0 other
comp.insurance required.]
x.Any applicant that checks box#1 must also fill out tho section bel6w showingtheir workers'compensation policy information.
t'Homeowners who submit ihis affidavit indicating they Are doing all work and then hire outside contractors must subunit a new affidavit indicating such,
tContractors that check this box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
T arza are ernpl'oyer that is providing woAfers'compensation insurance formy employees .Bellow is thepolley an4job site
information.
Insurance Company Name:.
Policy 4 or Self ins.Lie,#: Expiration Date:
Job Site Address-, City/State/Zip:
Attach a copy of the workers'compensation-policy declaration page(showing the policy number and,expiration date).
Failure to secure coverago as requiredunder Soction 25.A.ofMGL o.152 can lead to the imposition of criminal penalties of a
fine up to$1,50 0.00 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.
X rlo li Berta under� Tie azrz� enaXtzes true and correct.
ere? ' tw s arzrt a er'u Mat the in azmatz Dateavicle alra 62 �r tr.
Sitrnatule.
Phone#: '(' ,
Official use oily. Do not write in this area,to be eompleted by city or town official.
City or Tow-u: Perrnit0cense 0
Issuing.Authority(circle one):
1.Board of Health 2.Building Department 3.Czty/Towaz Clerk 4.Electrical Inspector 5.Plumbingynspector
6.Other
Contact rerson: Phone{#:
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