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Home My WebLink AboutWiring Permit - Permits #12954 - 32 LAVENDER CIRCLE 12/2/2014 w Date... . .................. O�p►ORTIy,~C TOWN OF NORTH ANDOVER ►- p PERMIT FOR WIRING ,88ACHUS�t0. This certifies that k" 6 .........'w ..................... _ has permission to perform .....................0 ' :...... . .......... e wiring in the building of...... .........`. at ........... ....... �..::.. .... ...° ..... ............... .....`..... .......North Andover,Mass. Fee..... A...............Lic.Nod .`.. k. .. ....... ................................I....................... qq ELECTRICAL INSPECTOR fh y Check# .hy, o � A commonwealth wealth of Massachusetts Official Use Only Permit No._ a epart ent of Fire Services Occupancy,and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEA SE PRINT IN INK OR TYPE,ALLMFOR.MATION) Date: City or Town of: NORTH ANDO''VER To the Inspector of Wires: By this application the undersigned gives notice of his or her int ntion to p orm the ele trical work described below. Location Street&Number ( _ ) o t� L Owner or Tenant ) i�, ` y 1(+,A, Telephone Now Owner's Address _G %,j Is this permit in conjunct ia with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building I - l` U ility Authorization No. r Existing Service 11 Amps f)0 JI/LVolts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7 � Corn letion of the ollowin table may be valved by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators I�VA No.of Luminaires Swimming Pool Above ❑ In- ❑ 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 Burners No.of Detection ting Devi es No,of Ranges No.of Air Cond. Total No,of Devices Tons g No.of Waste Disposers Heat Pump TNumber"Ton KW No.of Self-Contained otals: " " •' ..••.....•. Detection/Alertin Devices No,of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:*. No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: lA Attach additional detail{tdesiredl or as required by the Inspector of Wires. Estimated Value o 1 rj al Work: (When required by municipal policy.) Work to Start: f Inspections to be requested in accordance with MEC Rule 10,and upon completion. +� INSURANCE O (RAGE: 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:) FIRM NA .6r e altt s ofpetjtrt�y �the o this plicatian is true LICeNiO Lela o certi under t al and p (Ifapplicab epter exern t1 i_nn the hc� amberlin Srgaet " e Bus.Tel.No.; °' m /�"J" Address. // /r ) 1 Alt.Tel.No. J—L *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie,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 --- t Signature Telephone No. PERMIT FEE: The commonwealth of Massachuffetts - - DepartrnentoYIndtfstrIgIAceIkl is Offlee ofXavestigations 600 Washington.Sheet Boston,MA 02111 Uf www.massgov/dia Workers' Compensation insurance Affidavit: BnildersiContrcactor$fElectriciaaas)PIuuabeycs A licant Information Please Print lie 'bz Name(Business/Organi�zationlXndividual): i Address: _ Ca. /Sta�e �� Are youu an employer?Check the appropriate box: Type orproject(required): 1.RI am a eanployex with a d•• ❑ I am a general contractor and I 6, r]New construction F employees(full and/or part time)* have hired the sub-contractors ,i Remodeling 2,E] I am a sole,proprietor or Partner- listed on the attached sheet. These sub-contractors have 8. ❑ n Demolitio ship and•have,no employees workers'comp.insurance. g. Building addition working forme in any capacity. 5 � We are a corporation and its �10 workers' comp.insurance 10.E(Electrical repairs or additions officers have exercised their required.] per right of exemption MGL 11.[]Plumbingrepairs or additions 3.❑ I am a homeowner doing all work p p 12,Q Ro of repairs myself.[No workers, comp. c.152,§1(4),andwo have no insurance required.]► employees.[go workers' 1311 Other comp.insurance required.] MAny applicantthat checks box#i mustalso fill outthe sectionbel6w showingtheirworkers,compensationpolleyWorrnation. i'Homeowners who submit this affidavit indicatingthey Rre doing allworlc and then hue outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,pollcy information. I am an employer that ispr'oviding wotlters'compensation insurance for my employees. petow is the policy antijob,site information. Insurance Company Name: v 1 Z Policy 1�or Sel.ins.Mo.#: Expiration Date: Sob Site Addxess: City/stateizip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). FaHuro to secure coverage as xequiredunder section M of MGL o.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 civitpenalties in the form of a.STOP-WORK ORDER.and a fine of up to$250.0 0 a day against tho violator. Do advised that a copy of this statement may be forwarded to the Office-of Investigations of the DIA r insurance co v a�-vexiatzon, X do here iy cert' r lie pains tcr2ct penalties o�peYjury that tile information provided alcove T ftue a correct. Date: l � •�" / a r Phone#: `1-7 Official use only. Do not write in this area,to he completed liy city or town official. City or'�'o�vrn: Permit)License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PXuzubzngxnspectox 6.Other - Contact Bers on: Phone#f: r r� i �OMMIJNWpLTH OF . i MAS�A�MIJ'SET7'S; . ' ' e flAFp Q ECTR I C I ANS> ISSUES THE, FOt LOWING I ICENSE S A (S.TERED MASTi ..R ELEC:T�.I CNI N $ OTHEF2S HOMEt .WIq{ SLRV(CE'S'� I C �� I� F M> LVIN JR 227 MAIN 'ST Al';, LLI F 1' NORT1V ANDOVER MA 01$4 251,0 J wm. r.,