The URL can be used to link to this page

Home My WebLink AboutWiring Permit - Permits #12748-1 - 169 LACY STREET 10/6/2015 Date.A/V" ......... . 3a:NORT",tioo TOWN OF NORTH ANDOVER o PERMIT FOR WIRING 9i +,no 1y48q :HU`yfc4 `v Thiscertifies that ...................................................... ........................................ has permission to perform .. r � . ...... ..... �... —a .... 'wiring the building of............................. . _ ...... ............................................................. _kk� = North Andover,Mass. Lic.No. ..........I............ Fee..... :........... ELECTRICAL INSPECTOR �r Check# — t C®anmo n wealth ®f Massachusetts Official Use Only Permit No. Department ire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION MIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wines: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)j (°q Ln t;i 9� Owner or Tenante p�, �_V t _ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Res"A, � Utility Authorization No. T - Existing Service 2O0 Amps ° / Jkk4 Volts Overhead [C Undgrd❑ No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity 1 Location and Nature of Proposed EIectrical Work: �. Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell: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 mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switclies No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of WasteDis Disposers Heat Pump Number Tons KW No.of Self-Contained p Total : .... ........ ....... ............. ......... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No. of Dryers Heating Appliances KW Secuur tNo.o Dev es 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 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 rend penalties ofperpury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: ,t , �n�FQ Signature LIC.NO.: (If applicab el, enter "exempts in the license numberline) Bus.Tel.No.:023 471-Id"16 Address: 0o i"<- 1n/e Me, o yy,(, Alt.Tel.No.: Per M.G.L c. 147,s.57-security work requires Department of Public Safety"S"License: Lic.No. �-j) u 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 PERMITFEE.- $ Signature Telephone No. -� ", o� P vv,,.'� l�\C1 C:�' The Commonwealth of Massachusetts Department of IndiusirialAceldents �:= r X Congress Street,Stdte 100 ' d 02TX4 2017 Boston,MA www.mass.gov/dia OEM sv� ' e Affidavit:Builder/Contractors/Electricians/,plumbers. VQa�:kexs'Compensation Insuranc TO BE FILED WITRTHEPERMCTTING AUTHOItITi'. Please Print Le 'bl A licant lnfoxmatzon 1 Name(Business/Organization9ndiv1dual): Ct' l.� L Address: Yo Phone#: �7 ��" ?�q City/State/Zip: :. ._ A.reyou an employer?ChecJc the appropriate box: Type of project(xecluired): - em to ees firll and/or part-time).* 7. Q NeVd6nstr6 ion 1.[_]I am a employer with P y ( 2.[1I am a sole proprietor or partnership and have no employees working for me in 8. F]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[]lam 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 11.❑Electrical repair's or additions ensure that all contractors either have workers'compensation insurance or are sole 4 proprietors with no euployees. 12.[]plumbing repairs or additions 5.❑I am a general contractor and Ihave hiredthe sub-contractors listed onthe attached sheet. 13,0 Rb6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41,must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached'an additional sheet showing the name of the sub contractors and state whether or not(hose entities have ontractors have employees,they must provide their workers'comp.policy number. employees. Ifthe sub-c 'compensation insurance fol.my employees. Below is the policy andjob site X am an employer treat is pr'ovidingwor leer's information. Insurance Company Name: Expiration Date:, policy#or Self ins.Lie.#: City/State/Zip: Job Site Address: compensation policy declaration:page(showing the policy number and expiration date). Attach.a copy of the vc�oxkexs' Failure to secure coverage as requixed under MGL e. 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 WORD.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 Znvestigdtions of the DIA.for insurance coverage verification. X do lier^eby ceralfYdiepains andpenalties of perjufy fleet the information provided above is true and correct Date: Si ature: Phone#: C Official use only. Do not write in this area,to he completed by city or town official. Permit/License# City or Town: issuing Authority(circle one): 2.Building Department 3.City/To 1.Board of Health. vvn Cleric �.Electrical Inspector 5.Plumbing inspector 6.Other Phone#: Contact Person: Please visit our web site at http://wwvj.mass.gov/dpl/boards/EL MARK LUPIEN (EL) 19 LAKESHORE DR N WESTFORD MA 01886-1534 Fold,Then Detach Along All Perforations TH OF WEAL BOARD OF ELECTRICIANS — - ISSUES THE FOLLOWING LICENSE AS 4 REG ;JOURNEYMAN. ELECTRI CI AN:. , MARK .LUP I EN 19; LAKESHORE OR N , . U WESTFORD MA o1886-1534 51,41 07/31/16 27'-82