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Home My WebLink AboutWiring Permit - Permits #13339 - 81 LACONIA CIRCLE 5/27/2015 Date........ ................... OF TAORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ................................ ........... .................... ......................... has permission to perform ....... ..... y ......... . ... ........ wiring in the building of.... ........................................................................................... ................................... ............................... 'o�h Andover,Mass. Fee .......Lic.No. /-j • ................. ..... ......... ——ELECTRICAL INSPECTOR ---------- Check# Commonwealth of Massachusetts Official Use Only 17 Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PPdWTININIC OR TYPE ALL INFORMATION) Date: S" �i S City or Town of: NORTH ANDOVE'R To the Inspector of Wires: By this application the-undersigned gives notice of his or her tentiontoperform, the electrical work described below, Location(Street&Number) LAcc,��a4 el�,O-ca� Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with uild .permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building st tj& t=L4 f,-j 6 Utility Authorization No. Existing Service- Amps volts OverheadF] Undgrd[I No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: U11 111%2- ytwl IfIX Z'r 5,41T Completion of the fallowing table Ynay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above Ei In- F] 0. 0 Ut mergency Lighting grjid. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners JIM ALARMS INo, 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 Dis osers Heat Pump JKW No.of Self-Contained p Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local[j i Municipal [j Other i Connection No.of Dryers Heating Appliances KW iSecurity 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 Telecommunications Wiring. of Motors Total HP No.of Devices or E ouivalent 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:.-15 ,t 5 Inspections to be requested in accordance with YIECRule 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 F1 OTHER n (specify:) lcerfify, underilw allisand enalflesof�peijuyy,thatfliei rination on this application is true and complete.FIRMNAM —76r7,6`5 I-6,40-g.-P LIC.NO.: Licensee r-1 it ... LIC.NO.: j&6,,,y oo p,jjqk t,,_ Sigiiatut'--- (If applicable, x t"', , the Idine -I Bus.Tel.No.: einp in e e num ,� Alt.Tel.No.: Ai vo *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"LZ se: Lic.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)D owner 0 owner's agent. Owner/Agent Signature Telephone No. P k"IT ME=. The Commonwealth of Massachusetts z Z Department of IndustrialAccidents „ -- --- I Congress Street,Suite 100 �< Boston,MA 02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): ,4-h C;I- Address: Z 6LU C c�_ R. City/State/Zip: tt`' 4JU d A l r Phone#: Are you an employer?Check the appropriate box: Type of project(Pequired): l.❑I am a employerwith employees(full and/or part-time).* 7. F1 New construction cQ 0 I am a sole proprietor or partnership and have no employees working for me in 8. (1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself,[No workers'comp,insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.M-lectrical repairs or additions proprietors with no employees. - 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *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 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 jab site information. Insurance Company Name: Policy#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 coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the Pains and penalties ofpeijui if t-the information provided above is true and correct. Sign t re: �^ Date: Phone#: 1 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License it 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#: ,4 COMMONWEALTH OF MASSACHUSSTTS BOAEC3 OF EL:E.GTRICM ANS ' gnaw I � ISSUES THE' FOLLOWING LICENSE } AS A 6- ,JOURNEYMAN -;ELECT,R I Cand umpim JAMS9IS KOUYOUMJ6 65 LOwman Dow— ELL...RD f�J NORTH READ 1.:N0 MA 01864 1635 5161 _ ..._27440.