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Home My WebLink AboutWiring Permit - Permits #12389 - 107 LIBERTY STREET 5/28/2014 Date . .. ............. O f NOR'rh�a . ? ab TOWN OF NORTH ANDOVER a PERMIT FOR WIRING B�ACNU'3� This certifies that .... . .. ' � '� ..` ° �" w Po �. ..... ....... . . !4c.... ............................. f has permission to perform " , t' ,p wiring in the building of ` at ........... .... ..� ��...�.. .. <........ ...............North Andover,Mass r ....Lic ,. e• .. f ELECTRICAL INSPECTOR E '" ;G Check# � g� — C.Innwnweamt ol maijac4uiettj Official Use Only 1"2,, 2epartnwnt ol3ire ServiceJ Permit No. ')�,, I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: An r#j To the Inspector oj'Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /0 7 ......--s 51:!5t,.f Owner or Tenant Ir—4 rr Telephone No. Owner's Address an e- �9�,emz, Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Put-pose of Building (e. Utility Authorization No. Existing Service Amps Volts Overhead n UndgrdE] No.of Meters New Service Amps Volts Overhead El Undgrd n No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: C. ("6/,1"- Completion of the fiollowingtable may be waived by the Ins ector of Mires. No.of Recessed Luminaires No.of CeilSusp.(Paddle)Fans No.of Total .- Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators 1,CVA —. Above In- r--j N`57.5T"15fiergency ighting No.of Luminaires Swimming Pool rm El gnd. ❑ Batter y Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges RLCAir Conj' Tons c5z No.of Alerting Devices \) Heat Pump j.Numhe,i.-.1T9.ns KW No.of Self-Contained No.of Waste Disposers Totals: . ..... ....................... Detection/Alerting Devices ❑ Municipal F] Other No.of Dishwashers Space/Area Heating KW Local El Connection No.of Dryers HeatinSecurity Systems:* �w g Appliances KW mt No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices oi-Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrica Work: 6,� (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 CON e is in force,and has exhibited proof of same the permit issuing office. F1 CHECK ONE: INSURANCE ov 'BOND ❑ OTHER n (Specify:) Grp I certify,under the pains and X)enafties of perjury,that the information on this application is true and complete. f7 I LIC.NO.: FIRM NAME: jet A-0s .&I Leo ne?hy - Licensee: Signature LIC.NO.: (If applicable, entgx 11- exeinj)t"in the license number fiqg.) Bus.Tel.No.: I t)e Address: IV/if Alt.Tel.No.: *Per M.G.L.c. 'r47,-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 avent. Owner/Agent PERMIT FEE: $ Signature Telephone The Commonwealth of Massachusetts Department of IndustrialAccidents T Office of Investigations m 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �� Address: City/State/Zip: _ L'` ; P i9 �� j Phone#: rat L/ Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2. I a sale proprietor or partner- These sub-contractors have g, ❑Demolition shipip and have no employees working for me in any capacity. employees and have workers' 9 ❑Building addition insurance.$ [No workers' comp. insurance comp. 10.❑Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, 1and. have no 1 ❑ Other employeees.s. [[No workers' kers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f iiomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I m rrn employer that is providing workers'compensation insurance for my employees. Below is the policy and job site a information. Insurance Company Name: Policy#or Self-ins. Lic.#: 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 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 verification. I do hereby certify unde he pains and penalties of p Jury that the information provided above is true and correct. Signature: A# Date: C7 0' , , Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# LLthh ority(circle one): ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector on: Phone#: HUse.. tEC�R l:C 1 ANC 1SSllfS �H �OLLOWCi tD JOtiRNEYA ELECCRI M lEONARD SR Z ` ..: 1 DEXTERl MA 01844 5419 f > .OTH�EN b4441 81 07I3 ./16 --