HomeMy WebLinkAboutWiring Permit - Permits #12892 - 81 LACONIA CIRCLE 11/12/2014 Date.....I
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
V .
CHU
This certifies that
has permission to perform .................. ......
ys
wiring in the building of......... 4.,
.............. ....... ................................................................
at
........... ...................... North Andover,Mass.
1c.No. .... .............. ... ....
ELECTRICAL INSPECTOR
Check#
Commonwealth of Massachusea,,3 Of Rcial Use Only
• MEMO Department of Ffro Services
BOARD OF FIRE PREVENTION REGULATIONS
'I an_as Occopai c y d Foe.Checked
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APPLIGAMON FOR PEPPfl*l"r TO PERFORM ELECTMA'L WORK
Mwork to be crfojmed in accordance.1,4th..ft l fagsacfiu efts d fecirical Code(MMQ,527 CAdR 32.00
(T-0,419V PR2ATJNWK OR TYP—PALL Z FOR1&97TDAI) 2
City or Toyvh olfa. YY
To the Ills of Ores-
elforn-1 the electrical described below,
By this application the pedw
"I \ - ,4 tentio),�to 1)
Locatim.('131-reet&ilqlawbq) Z>
Owner or T.ovant LACDI-_:�177S
Oimerlg Addre-sg
xg ffi is T)erw it In c Oxil'a I I C t i 0 V.11ith a MI.i.161 -,p e f,f Yes F] mo, (Check Approprlate)3ox)
vorpws0 Of Bu-!Tdu9---_
Amps I Voles Overhead F1 undgrd D 1\10"OrMeters
Amp Volts overhead EJ wgrci D No.ongeters
XM-ab"of Feeders and AinpacRy
'Location aud Mtnra of�.roposed Ejectrical W or.k. ry
Co?,Wk t`*o n offli c fo 710 w rig to h le may he i P aA,e d by f7l e h 7SP e C 10)-0/
No.0 Peeossea Luminaires MO.of ceff'susp.(Raddle).Fans 0 JN 0,Of Total
,)O"ffl 1�a s " N
Tr )2s.formem XVA
of No.of Hot-Tabs MrA
177 113-1
"Mmyo --� I—n- , f- o.
No.of I'laninair,5 SWImraffigrnol E]
No.of oatleft Na,of(11 Banters ALARMS -Xo.of Zonesff
No.of&,ftche-s Muetecuox(and
INO,of has B b3iffiatiAg Dvi
ces
NOs OfRang-es No.of Air Co)jcL To
INUS No.of Alq�, rtg Devices
No.of Waste.'Wsposers ffeatRump Number I Tons xw WO.of Sold Contained
Totals.
No.of Djsylwashox-8 JSnce/Area:ffeatlxig Kw Conuect
"I * -on ❑ C11her
IN f DXYUS HeatiugAppli-quees
1110.Of De-),Ices-or'S'Quivale&
NO.Of
ff eaters XTY
Signs Gallasis NO,ofDevicesorF, trivalent
Na. EFF
rrir¢ch adriztioniddetail ifdexirec{or ax reqvircdby 47ic-67specor of fires �
FstiMate-d Value of EloctricalWork: 2" 01/hen required by muaicipal policy.)
WorktostaTt, lns-pertiomtobereqiiesfedin accordance vr?�h��IECRulolO,audapoiirompl�3tion.
)VSURAXCE��OWRAG)C., Uales-g-walved by the otxner,.no pezzaz7t for the Porformanco of alectrical-workinayissue unless
the licensee provides proof ofliabiliiy insuragee including"complotcd.op.aatfon coverage Or its substantial eqaivalent j:ho
undersigned cezf&s that such collerago is infOrce.,and has exhibited p):oofo,-fsame to the permit issuffig4).office.
CfMCK ONTF: )INTSUMNCp, [] BON-11) Ej OnJER X (Speojfy.) Self-fMSI)red
lcerafy,under the audpejaf
palay (jes'ofperjuly,that the inforwafloft 071 this 1717PYWITOI1 is true andeoinpldr,
RW)"XINMUz ADTfLC)D)3AADTSecurity LIC.M.- C-17-9
Mcemee; Thomas Y.Lev
(VaPPA-hte. Bas.TO,140,Z-
Address:
AR,Tel.NO.- -
8c0mifY 83,stern requirea Yor tb id plicablo,enter ffio license nu-rj or hcre: 001,779
0VME,R-'S INSTURA-IN'CE WAXCM I am awaza thatthe.Licensee does 770t have the,liability msinance coverage normally
"required by law. By my signature below,I hereby waive this requirement f am ta8(check one)Q ovener 0 owmes agent
Gvvmer/A.e,eut
55III.7T IT-i�$
L r
The Commonwealth of Massachusetts
Department of IndustHal Accidents
> Office of Investigations
d 600 Washington Street
K Boston,MA
®�y2�.l11
'�3yA0 SNVy`ry4a �YYYYV.m aJs.goV1dia
Worji,ert°, Compensationff nsurance Affidavit. Bui ders/Coot ractors/Elect ici'ans/PIURnIkDerrs
➢icantHilifomationa
Name (Bus iness/organization/Indiyidttal) j-\
Address: `� _._ _-�_.❑�"..E—_ �_.�.,__.
City/Mate/Zip: =D.� 7 �'s� Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.[A-I am a employer with_\Cl(JC?'+ 4. ❑ I am a general contractor and I 6, ❑New construction.
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am sole proprietor or partner-
listed on the attached sheet. ? y ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
i working for me in any capacity. workers' comp. insurance. 9, []Building addition
j' [No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.ElI am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13. `° Otlaer
comp.insurance.required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy infonnation.
t
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 cyan an employer that 1s pr'oviding workers'compensation insurance fore any employees. Below is the policy rand job site
information.
9 kx € f f a,, �
Insurance Company Name: .
r a
Policy#or Self ins.Lie.#: t,. rtpkrar!.oaa.D�le_ r
l t s
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 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 verill:•ation.
y I do'her•eby certify'under the pains) nd,ve.a des 9f`p'erjarry th at the info nnation provided above is trace(titd corract,
Phone# a'
�f�cial arse oraly. .I90 taot ivr^ite irz this•rarera, to he carr��lefed iry city or tarvar offacidl.
City or Town: - -_ _ _._— Perrnit/License# -----
Issuing Authority(circle one):
1 E..Board.of Health 2<Building Department 3. City/Town Cleric 4. Electrical Inspector 5,Plumbing Inspector
6.Other
Contact Person: --_ Phone#: