HomeMy WebLinkAboutWiring Permit - Permits #12638-1 - 32-34 LINCOLN STREET 9/2/2015 (f1mnwnwea&o/Maddac4udetb Official Use Only
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.,parEment o13ire Serviced Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 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: A,% —J
City or Town of: /1J, �d '�, 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) 3, — 3 d10 5f
Owner or Tenant V ti 4 6C eV1 Zi-) ip!1 -6 Y1 4Z Telephone No.q7Z 3
Owner's Address 3=� -•3 9 L w e'r9/y1 5"E A A1-4 CI(4�i—
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity r
Location and Nature of Proposed Electrical Work: re fk t7,_17n-
Com letion Qf1hefiolloiving table may be waived by the Inspector of 6f"ires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans a No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above El ❑ o.o EmergencyLighting
rnd. rnd. Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARINIS No.of Zones
No.of Switches No,of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Nmnber I Tons KW No.of Self-Contained
Totals: .."'.....................""'"' .. Detection/Alerting Devices
No,of Dishwashers, S ace/Area Heating KW Local Municipal
p g ❑ Connection El other
No.of Dryers Heating Appliances KWSecurity Systems:*
No.of Devices or Equivalent
No.of Water KWNo.of No.of Data Wiring:
Heaters Si Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of thires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: '� 1 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 andpenalties ofperjury,that the information on this application is trite and complete.
FIRM NAME: LIC.NO.:
Licensee: r 11�efsaA Signature/ LIC.NO.:
(Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.: ci
Address: 4 I1G i3 s;$.�a`.�i. 5e_ L s, i1AA— Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security worl 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. iy 'gnat 8' low,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agen p 9 `" PERMIT FEE: S_j —
Signature Telephone No. �� 3�
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Date........ - �........:..::... .. ..........
N°arM
TOWN OF NORTH ANDOVER
a PERMIT FOR WIRING
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88ACHUS��
This certifies
has permission to perform ...N `........... e.........A a ':�:�.................................................
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wiring in the building of.... �.,,,,t l+ a �',......... ...............
at .....,North Andover,Mass.
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Fee. K . ...................Lic.N�o. ....... ...t.. t . ..... ..`
EL Ell. cALINSPECTOR
Check#
9
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� The Coninionwealth of Massachusetts
Department of Industrial Accidents
Off ce of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information '' ff (� Please Print Lelzibly
Name (Business/Organization/lndividual):��'l� C`5oVi
Address: 4 a
City/State/Zip: fv'.V-A Phone#: `V-9 m 9,�2C� rl
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
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.,Q I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$•
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.,,required.]
am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 am an employer that is providing workers'compensation insurance for my entployees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-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 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 under thepair andpenalties ofperjury that the information provided above is true and correct.
S' ature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
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#:
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