HomeMy WebLinkAboutWiring Permit - Permits #12546 - 15 LISA LANE 7/23/2014 A
Date,
of Noary J-2-3......
TOWN
a OF T
FI AN®®V
ER PE:R� 1'r FO
WI
�. 9�g fO AI t�g RING
,Co
HUSE
6
+ This certifies that e
—� n ..6 ..... � C ...
has Permission to Perform
� k ��•�- �VVV'
1 P orm -- � .........
J "Ing In the building o "� �`
....................................
at
�ae. .........L
..: .. ..........
Fee... � _ ..
Lic.NO. North Andover,Mass.
Check
p�
1 eck
#
LECTRICAL TNSPECTpR� a+.�
L� J
auimiuriaa[i/c o�I/Iitiiac�sttda i Official Use Only
•Uaparfntnnf o�yiry 3nrukad PermItN0- Z S
BOARD OF LIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev"/07]] (lemreb)ankl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL '1 O
RK
All work to be performed In accordance%vith the Massachusetts Electrical Code oaq,M7 CMR 12.00
(PLXISEPMff,W.WW OP-T I PB A U h VFOJ MMTrOA9
City or Town-of: A -)O r¢A Avolo(leg To Date:the Inspector of J�ril•es:
By this appltreet the undersigned gives notice of his or her Intention to perform the electrical work described below.
Location(Street&Number)_ /S- - t"s C�- Z CL rva
OwnerorTenant fit"/ y
Owner's Address Telephone No.
Is this permit in conjunction Ivith a building permit? Yes [
Purpose of Building /-Fay; I y �Vve 10ly q No ❑ (Cheek Appropriate Boa)
Utility Authorhntloa No.
EXIS ing Service Amps t Volts Overhead❑ Und
t'rd❑ No,of Meters
New Service Amps / volts Overhand
Q Undgrd❑ No.aflVleters
Number of Feeders And Ampacity
Location and Nature of Proposed Electrical Work: ®v ,� 1-'1VI
Cori etian n/7he fallarvin table may be waived r ille Ira eclor a l)?res
ffNo.tof
tecessed Luminaires S> N%of Cell,-Susp.(Puddle)Fans o•of X�A uminaire Outlets Transformers
No.of HotTubsGaaerators , ICVA
nmiaalres Swimming Pool Above ❑ In- ❑ o.a emergency t erg
ad. rnd. Butte Units
No.afReceptncie Outlets /,S' No.of Oil Burners �=- AL,AItIViS No.of Zonal
No.of Switches No.of Gas Burners o,ofDetectioa an
No.of Ranges Initiation Devices
No.of Air Conti. TOf°I No.ofAlerting Devices
Heat: Tons
No.of Waste Disposers Pum p umber ors IC o.of eIf- on
'IbtaN., Datection/Alertln Devices
No.of Dishwashers Space/Area Heating ICW Laval❑Muni pal
Conned—n ❑ Other
No.of Dryers HeatingApplinucas Icy FDa=ta
o.of aterICEV No.of No.Of-haviees or E ;Lalent
Henters o.of Wiring:
Si ns Hallnsts .of Devices or Ir
No.Hydromassn a Bathtubs No
Wiring:
g Na.ofMotars Total HP
O"TWER: No.of Devices ar>j nivnlent
�l uadt adorflorwt detail ifdwhwd.or as required bi,the IirspeGar a rres
Estimated Value of Electrical Work UU O (When required by municipal oli
__ policy.)
Work to Starr Inspections to be requested in accordance with Iv)EC Rule 10,and upon completion_
__..._..INSURANCLr-COYEItAG1;;=Unless=waived-hy4he=o�vrer�tio.peilnit foe the=pe'F#'omiEuice ufetecWcEil=wnilt mew=issue u sss
the licensee provides proof of liability Insurance including ucompleted operation"coverage or its substantial equivalent: The
undersigned certifies that such coverage is in force,and has exhibited proof ofsome to the permit issuing office-
CHECK ONE: INSURANCE t& BOND ❑ OTBER [] (Specify:)
I certify,under trio arns mid penallfes ofperjilrp,curl,the illlrommams all tilts appl1eq,101,is trlle turd C011ll�let4'FII�MNA11iE: ;card; �tec6 �
Licensee: a��' : LTC.MOB:.
Signature LIC lYtJ:e''-'5902-
lllal�Flfi ably enter u mpt"in!gin license number line.)
Address: ILA -(�t'C•/S-nn�P IJ � �`C A..A Bus.Tel.No.t I-i
Per A0L(J L.c.1'17,s.57 6I,security work re u » Alt.Tel.No.:
OWNER'S INSURANCE gwres Department of Public Safety S License: Lic.No.
WAIVER: I am aware that the Licensee does not have the liability insurance coverage norm
al y
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a nt
Owner/Agent
Signature Telephone No. PElil)1'I1'F EE.$
i
i
Rio
` i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgations
600 Washington Street
Boston,MA OZIII
www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information R Please Print Legibly
Name(Business/Organization/Individual): I>ifr.Q r tY ,eAt:C,C
Address: Gke i Sal, Rb,
City/State/Zip:�G►.y�'�V S M A M G 0 & Phone#:
Are you an employer?Check the appropriate box: Type of project(required,,.-
1.®-I am a employer with `A 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6- ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet.* 7. ❑Remodeling
sr:p and have no employees These sub-contractors have 8. ❑Demolition
,Working-for me idAny z.a acity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its Electrical re airs or additions
required.] officers have exercised their I X p
3.❑ 1 am a homeowner doing all work right of exemption per MGL ! I I.❑Plumbing repairs or additions
myself_[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all wort: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 their workers'comp.policy information.
Ian;an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: CQVq%MICCC.. *Xt%S
Policy#or Self-ins.Lic.#:_ 'PMPA D T3GT.) L Expiration Date:OG♦ 11.
Job Site Address: 15' L i SSA Lc w'P 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 thepains andpenaldes ofperjury that the information provided above is true and correct
Sip-nature: Date:
Phone#: 7 t I' ;k31! {177 -
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 S.Plumbing Inspector
6.Other
Contact Person: Phone#-