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Home My WebLink AboutWiring Permit - Permits #12057 - 169 LACY STREET 12/16/2013 Date..h �:, �•� E�.......... TOWN OF NORTH ANDOVER ?; p PERMIT FOR WIRING ,BgACHUg� r es that 'This certifies G has permission to perform k �' ............................................ wiring in the building of... s 'f orth Andover,Mass. `J 1, Lie,No d: a �`r( AL INSPECTOR Fee.... y.. ELECTRT Check# °"_ -- ---- Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NIEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / 3 City or Town of: NORTH ANDOVER 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 Tenant Telephone No. 5,,� Owner's Address Is this permit in"conj unction with a buildin permit? Yes n^ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps volts OverheadF] Undgrd❑ No.of Meters New Service Amps Volts OverbeadF] UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: SLQ , -k,/ i LA— Completion of the fallowing 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 Ei In- ❑ N—o.—OTEmergency Lighting Rrnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil)Burners FIRE ALARMS No. of Zones No.of Gas Burners No.of Detection and No. of Switches Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons -j No. of Waste Disposers Heat Pump J.KWI., No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal n Other Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent AJ 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 11P Telecommunications Wiring: No.of Devices or Enuivalent 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 ism force,and has exhibited proof of same to the permit issuing office. CHECK,ONE: INSURANCE 0 BOND F1 OTHER n (Specify:) I cert?fy, tin der i ains andpenalties ofpeijuiy,thatthe litforination on this applicAlon is true andcoin Ilk) I", plete. FIRM NAME: LIC.NO.: Licensee: Signature_ ) LIC.NO..,a (Ifapplicable, enter "exempt"in the icense member ne.) Bus.Tel.No.: Address: 6t),311, Alt.Tel.No.: lw,7 ?15, *Per M.G.1,c. 147,s.57-61,security work requifes Department of Public Safety"S"License: 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)EI owner []owner's agent. Owner/Agent Signature tore No. PERMIT FEE. $ .,95 The Commonwealth of Massachusetts Department of lndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 QV www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly • Name(Business/Organization/Individual): V Address: L Akro_ytli Z1,7 City/State/Zip: w ,VV" 70'.),�4, Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.D I am a employer with 4. n I am a general contractor and 1 6. E]Now construction employees(full and/or part-time).* have hired the sub-contractors 7. n Remodeling 2.12q I am a sole proprietor or partner- listed on the attached sheet.I ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers' comp.insurance. I [No workers' comp.insurance 5. El We are a corporation and its 9. E]Building addition required.] officers have exercised their 10.F1 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12TIRoof repairs insurance required.]i employees. [No workers' 13.EJ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a now affidavit indicating such. fContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or S elf-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 requiredunder Section 25A of MGL o. 152 can load to the imposition of criminal penalties of a fine up to$1,500.00 and/or ono=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. S doherelycert under the�wl�s andpenalties ofperjury that the information provided above is true and correctloe!Mature: �-,11 Date: 73. Phone# (J(S' c9- J Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 0 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 MASSACHISETTS Dim BUAf�D�3F E"LECT2AVIANS I SSUES THE F0L>LWIN' L�CENSE AS A RED JOURNEYMAN ELECTRICIAN:: `w r a ' STEPtEN E BUKER F 20 CABERNETLN z ..''Pi�YMOUTH _ MA 02360-7708 2 07/31/,16 37.114 F MASS.... USE I,�AIS ' - l SSUES THE FOLLOW!NG L I GE<�SE A`5 A � ., 8�0[STE�EO M�tSTER EL�ET�IGI~A } BR 1',N E ELECTRIC LIG 1T :OEPT TEPHEN E B7li w' d: 3 Sf3�1 NTRE E #�A �}2184 1364