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Home My WebLink AboutWiring Permit - Permits #12865-1 - 21 DAVIS STREET 11/13/2015 Date... ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU5 ...A" This certifies that ................ ..... A(" ............. .................................................................................... has permission to perform ............�.. e- 7`1-- .......... ....... wiring in the building of ............. ......................................................................... may at ............... .......... ...... ..............I......................North Andover,Mass. Fee....5-5......... Lic.No.0 L5.................................................................................... ELECTRICAL INSPECTOR Check# Commonwealth of Massachusetts omnht Tiou WY ` @ Services Permit No. I l J �?ar'tiilrlt® rl' U --- BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRtCAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),547 CIvllt 12.00 (PLEASE PRINT ININK OR TYPEA IXFOR 7IOA9 Date: -- city or Town of: /� �-�. ' ��t:��A � _ 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 Tenants r r'�". G'�� Telephone No. Owner's Address <i_r—r-g Is this permit in conjunction with a building permit? Yes ❑ - No W Building Permit# Purpose of Building Ttility Authorization No. Existing Service 'eL� Amps / Volts Overhead Undgrd❑ No.of Dieters New Service Amps / Volts Overhead❑ Undgrd E] No.of Dieters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ; w (' ",J Co5ektn o the ollowin table maybe waived the Ins ector o Wires. No.ofotal No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators XVA Above n« o.o mergency g No.of Lighting Fixtures Swimming Pool gad. ❑ grad. ❑ �B;ar Units No.of Receptacle Outlets No.of Oil Burners ALARMS No.of ,ones No.of Switches No.of Gas Burners o.o a ' on vi Initiatin Devices No.of Ranges No.of Air Cond. Ton No.of Alerting Devices ed No.of Waste Daspasers ► er ors _w, o.o e ontain Totals: ""� . Detection/Ale Devices No.of Dishwashers Space/Area Heating KW Local ® Conne P.on ® Other Heating.Appliances KW ecurity stems: No.of Dryers No.of Devices or E uivalent No-.o Ater o.o o.o Data Wiring: Heaters Sims Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP el�O m" ° r No. F of Devices or E wtvalent OTHER: INSURANCE COVERAGE: Unless waived by the owner,uo 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 ❑ OTMM ❑ (Specify.)._ - �,/ (Expiration Date) Estimated Value of Electrical Work.-4 /� r cam, (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC Rule 10,and upon completion. I eer#fy,under the patios andponfildo of pePjury,that the information on this application is true and complete.Current Irtsururtce cert�ftcate tnust6e on in our v#ke q,rmav�'1.orust�6ef*Ned v&Y rv� k each apptieadom _ , , 1b�I S FEW NAM: ,D.L' ` i9I��%zC jet � .�s 4 c LIC.NO.• Licensee: /422r _Si nature LIC.NO.: etrapplicable,enter " pt"in t license her 1t e.) Bus.Tel.No.° ��"'/°'� Address: �' il/ /'''�g �i S Alt.Tel.No. OWNER'S S E WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By ray signature below,I hereby waive this requirement. I am the(check one)❑owner owner's a cnt Owner/Agent EPE��ITI+M $ _�)!-- Signature Telephone No. The Commonwealth of Massachusetts kvDepartment of Industrial Accidents iOffice of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print]Legibly Name(Business/Organization/Individual): , ,G' ✓,Ya!� /�'C%Jl/C�/ /' E��i,�� /C Address: City/State/Zip: ��r_/�"�r �VV_ Phone#: re you an employer?Check the appropriate box: Type of project(required): 1.( I am a employer with c 4. R 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. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box M 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 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 my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: C��f V��'��1 / Expiration Date: Job Site Address: City/State/Zip:y1 , "r i 1/y/ 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 ai s and enald ofperjury that the information provided above is true and correct. Si azure r Date: Phone M Official use only. Do not write in this area,to be completed by city or town offaciaL 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#: Commonwealth of Mas�'Ousetts Division of Fegistrati „ Board of Eleotri �, - r MICHAEO GUS �_ 0 9 WAVEA j V NORTH A air ti Master Eleci 21705-A 07/31/2016 _t' 008772 i License No, Expiration Date. Serial No. GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: P�71)C,1« l�iV)S GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: ig ELECTRICAL. GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: Ie--4 v-eAr IA hvv-,,Ae- See- *ZONING DISTRICT: TPLANNING APPROVAL (IF IN WATERSHED) TION APPR*CONSERVA' OVAC North Andover MIMAP November 13, 2015 6 l` � pV lii�� 1� w rv7 �� Ill f llr r,l �(•l " iy r Ma i. Q I r 1 f r N � 125 6� � rya �a�et �-,• l I parker Street Q MVPC Be Interstates Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83, —SR Meters Data Sources:The data for this map was produced by Merrimack NdRTiy Valley Planning Commission(MVPC)using data provided by the Town of Roads Of y.��ao r North Andover.Additional data provided by the Executive Office of 'j Easements ,� ba 6R6 Qp Environmental Affairs/MassGIS.The information depicted on this map is Parcels 3 L for planning purposes only.It may not be adequate for legal boundary —• '' definition or regulatory Interpretation.THE TOWN OF NORTH ANDOVER ~ MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING �t * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 4T�p'�p"a g THIS INFORMATION 1S'gACNUs�� V=363 ft