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Home My WebLink AboutWiring Permit - Permits #13043 - 198 LANCASTER ROAD 1/6/2015 Date........ ...' .......... t&ORTN TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU ......... This certifies that ................................................... ................................................. b" has permission to perform ......L................................................... ................................................ wiringin the building of......... ................. .................................................................... -A 0 dover,Mass ..... at .......L.A...Ki.................. ........ ...... ...........t.,.................. Fee................................Lic.No. ......... ............................ . ............... ...... ............. ELECTRICAL INSPECTOR Check# AVVLIUA 11UN rUK r MIvtl I I v r r%rvR'w cLct-o i m1loPti. vvvr%r® All work to be performed in accordance with the Massachusetts Electrical Code(M C), 27 CMR 12.00 (PLEASE PRINT'IN INK OR TYPE A L IN O'WTION) Date: / 4� r" City or Town of: �<��' '- To the Inspector of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location(SheetBcNumber) ��"C<<S t'r" c7'l-) Owner or Tenant r, ,c� Telephone No. iarS' Owner's Address Is this permit in conjunction with a building permit? Yes No Q (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Set-vice Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders.and_Ampacity, 3 Location and Nature of Proposed lectrical Work: A -d,1 J , t .`W5 Completion 2ftheLbllou,ing table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil: Tr Susp.(Paddle)Fans o Total Transformers KVA No.of Luminaire Outlets No.4-Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ® - ❑ o•o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Bur No.of eteg and Devices No.of Ranges No.of Air Cond: Tans Initiating - No.of Alerting Devices No.of Waste Disposers eat Pump .umber Tons KW No.oSelf-Contained ` P ' " """"" Detection/Alerting Devices Totals: No.of Dishwashers Space/Area Heating KW Local❑ Munic►pai ❑ Other Connection No.of Dyers Heating Appliances KW eCuriNo. f Devices or Equivalent No..ofWater No.-of No.of Data Wiring: Heaters Sigps Ballasts No.of Devices or E uivalent No.H dromassa a Bathtubs No.of Motors Total BY Telecommunications NDevices r n►ng Y g No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of le tri 1 Work: � (When required by municipal policy.) Work to Start: 4, A5 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 cent ,under t/te pains at►d penalties ofperjurv,tth�t�ee informatfou on this application is true and complete. FIRM NAME: ✓ I 5 F�c ,n c Y /"t'de�. o /lo�S GLC LIC.NO.: )�dJ Licensee: �ef, �/ >hx'�� Signaturei'' LIC.NO.: (If applicable,enter "exempt"i the 11, ense number line. �J l/ // Bus.Tel.No.: Address: �? w� l x�>2Z,7,R .Hni/�1 %>Qt NFYF Alt.Tel.No.: `Idl-2V- W11 *Per MG.L. c. 147,s. 57-61,security work requires 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 ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ r-- �i�l � _ .The Commonwealth of:M•assachasetis - .Depaz�hV nt OfIndlistr�zccr Aceide�ats Office of fivesdgations 600 Washington Street Boston,.MA 02111 www.mass govlcira Workers' Compensation bsurance davit:Buiilders/ContractorsWee xzexa� I'wm� Please Print licant formation ' Name(Business/Oxganization/xndividud): )N2% / Address �lit/��i ,U tY' _ Ci /State/Zip:_AA), l m, /1A Phone .Are you an employer?Cliockthe appropriate box: Type of project(required): q• ❑I am a general,contractor and I 6. []NOW construction 1, x am a employer with — have hiredthe su'b-contractors employees(full.and/or part time). listed on the attached sheet. �. El Remodeling 2.Ell am a sole proprietor or Partner- These sub-contractors have Demolition ship and'have no employees workers'comp.insurance. g, Q Building addition working forme is any capacity. [No workers' comp.insurance 5. ❑ We are a corporation and ME]Electricalrepairs or additions officers have exereisedtheix required.] xightofexemptionperlvtGL l.x.Q�'l�h�gxepaixsoradclrtions 3•[] Zamahomeowner doing all work c•152,§1(4),and we have no I2.0Roofrepairs myself.[,No workers comp. employees.pTo workers' insurance required]i 13-El Other comp.insurance required.] x.Any applicant that checks box#1 must also fill outthe section below showing their workers'eompensationpolit s information. i-Romeowners who submitthis affidavit indieatingthey M•re doing allworlc andthenhire outside contractors mustsubmit anew affidavit indicating such. ?Contractors that clzeckthis box must attached an additional sheet showing the name of the sub-contractors andtheir workers'comp.Voiicy information. X am arx employeN that ispx ovldhig worlrexs'compensation insuranee for•my employees; nelow is tnepolley and rob 4fe informallon. Insurance Company Nam r Expiration Date: Policy#or Self ins.Pic.0: G't�l�(� ��9 ) 7� Sob Site.h.ddress:.___/ .Attaclx a copy of the workers'coxap ensation-p olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section Z A of MOM o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or ona-year imprisomnoUt,as wellas oiv il'penalties in the form of a STOP WORK ORDER.and a fine ofup to$250.00 a dap against the violator. Be advised that a copy oftbis statement maybe forwarded to the Office-of Investigations of the MA for insurance coverage verification. X do Tier eby certify zrrtder• a' tt antes of perjury that the informatzon provided above is trite and correct Date: ' s S7 atu Phone Official arse only. Do not write in this area,to be completed by city or'town official. City or Town: Per mit/Lzcense -------------- ZssulagAuthority(circle one): I.Board ofnealth 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumb!ngxrtspeetor 6.Other y Phone#: Commonwealth ofMas usetts Division of Registrati Board of Electri MICHAXT 9 WAVE " o NORTH A d ti Master Elec 'a �w 21705-A 07/31/2016 f�qM sVev008772 License No. Expiration Date. Serial No.