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Home My WebLink AboutWiring Permit - Permits #12026 - 44 LISA LANE 11/25/2013 i Date..... ;z�z......r.? O�NORrA, TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,�BacHU This certifies that x ` � ...�. � ""has permission to perform t p y e,�c � s •� � '`,.°.:..i...�' T c ;�'P wiring inthe building of at ........... .............N dover, E Fee ,Mass. LIc.No ..a� G Check# ELECTRICAL INSPECTOR �_ th Commonwealth of Massachusetts Official Use Only Permit NO. Department 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(MEQ,527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: J I — i 'I Q City or Town of: NORTH ANDOVEi R 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 OwnerorTenant je— Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No [I (Check Appropriate Box) Purpose of Building 5"J,N�k-,Ecjy,, Utility Authorization No. Existing Service— Amps volts Overhead ❑ Undgrd F] No.of Mete'rs New Service Amps Volts Overhead F1 Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.o Total No.of Recessed Luminaires No.of Cefl.-Susp.(Paddle)Fans Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA Above Ei In- 171 —W-070TIRImergency Lighting No.of Luminaires Swimming Pool grnd. ❑ grnd. ❑ Battery Units FIR No.of Oil Burners FIRE ALARMS i No. of Zones N, o.of Receptacle Outlets No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained g Devices El No.of Dishwashers Space/Area Heating KW ILocal Municipal Totals: Detection/Alertin P Other Connection [ No.of Dryers Heating Appliances KW i Security Systems:* I No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devicesor Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Equivalent OTHER: J Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ZSCX, (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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [I BOND D OTHER El (Specify:) IcertIfy,iin(tel,iliepaiiisandpenalliesofpeijuiy,thatthe hfforination on this application is true and complete. FIRM NAME: LTC.NO.:Q G, > Licensee: Signature LIC.NO. (Ifapplicable, enr "exeing"in the license number line) Bus.Tel.No.':�I,,.) 4X- �3; Address: to G t,C,7( lv%A- c�i"'10 Alt.Tel.No. *Per M.G.L c. 147,s.57-61,security work requires 1)apartment 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)D owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in UG.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule R—Permit/Date Closed: **.*Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspecto s Signature: Date: ROUGH SP TION: r ss 0 Failed Re-Inspection Required($.) ❑ pectors Com ents Inspectors Sig Lure: Date: FINAL INSPECTI Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusefis Departmint of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeORY Name (Business/Organizatiori/fndividual): Address: 0%`)0(, Phone#: > e you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. n I am a general contractor and 1 6. 0 Now construction %1ployees(full and/or part-time).* have hired the sub-contractors 7. F1 Reniodcl*ing 2.El I am a sole proprietor or partner- listed on the attached sheet.$ ship and'have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. I [No workers' comp.insurance 5. El We are a corporation and its 9. []Building addition required.] officers have exercised their 10.F1 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.n Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.]t employees. [No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, f Jj-)Meowners who submit this affidavit indicating they aic doing all work and then hire outside contractors must submit a now affidavit indicating such. tci untractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I wn an employer that is providing workers'compensation insurance formy employees. Below is the policy and joh site information. Insurance Company Name:. Co&N&"cT Cc Policy#or Sol-f-ins.Lic. iAw Expiration Date;k 0 Job Site Address-, L-04 Lc-�t,e� Pity/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredundor Section 25A of MGL o. 152 can load 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. 1(10 hereby certtfy under the pains and penalties ofperjuiy that the information provided above is true and correct Date: s.—Signature: Phone#: 1�_X:2 Official use only. Do not write in this area,to he completed by c4 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#: I `ram:OOMMONWF,ACTH OF • • • , _ • MSSAmHUSETF� s ac�ARrs� ELECTRICIANS ISSUES' THE FOLLOWING 10ENSE AS ., REIaT�RED MASTER ELECTR7'C(AN :A c R1 CH{RD C P I CARD 1 JR zQ z 14 GRE':.: E RD t �: AAo190621f� 2052 A. . . 07/31/:16 39607 OMMONWEALTH OF MASS�GHUSETTS . SQARD'� ELECiRICtANS ISSUES THE FOLLOWING LICENSE , R JOURNEYMAN ELECTRICIAN F AS A ga C PICARDlu I JR R 1 'tARD ;, z 14 GREYSTONE' RD , SpiGu ' 1�A -21 0�90 • 277 39029 07�31�16' •F,, j