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Home My WebLink AboutWiring Permit - Permits #13265 - 82 LISA LANE 4/28/2015 f. Date F ............ O"t yORTH qti TOWN OF NORTH ANDOVER p PERMIT FOR WIRING o .1 a '�y�'�+;.'.o•',tag �BACHUS� • z - " This certifies that .......................................` .. ` has permission to perform ....�. "........ �s wiring in the building of � f at el.. ` ..........r ....6... ........................ ... North And o r,Mass. Feer: E ........ Lic.No. ..........:i . w ............ ............. ... �" " ......... . .... .. ... ........ ELECTRICAL INS CT R Check# Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. � Occupancy and Fee Checked F 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: City or Town of: NORTH ANDOVER 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) L L Owner or Tenant - ` Telephone No. 7q'` f Owner's Address - --� �/ Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building >�, Utility Authorization No. Existing Service� Amps )2v' Volts 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: Can letion of the folloii,in table ina y be iwii,ed 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 KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets 2 G. No.of Oil Burners FIRE ALARMS No.of Zones s No.of Switches / No.of Gas Burners No.of Detection and ( � Initiatin Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ................. ...•.. ...•............. Detection/Alerting Devices No.of Dishwashers ( Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers I Heating Appliances KW Security Systems:x No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER ,4ttach addi oval delait if desired,or as required by the Inspector of YVires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:94LJ /L 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 P/ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjuiy,that the inforination on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: ciyl�'S (/ ( 1 Yin Signature LIC.NO.: ) (If applicable, er r "e, nipt"in ilre!' erase n rnber line.) „ Bus.Tel.No.: Address: lZ eSli v v 5'co 6V 9'0 Alt.Tel. No.: *Per M.G.L c. 147,s. 57-61,security work req:i s 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 one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massach usetts Department oflndustrialAecidents 1 Congress Stt•eet, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia «corkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. p ilicant Information _ Please Print Lezibly Name(Business/Organization/Individual): ELG� Address: /x e City/State/Zip: Sao G /G Phone #: � ' Are you an employer?Cheelc the appropriate box: Type of project(required): 1,❑I am a employer with employees(Rill and/or part-time).* 7. R New construction 2. am sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]p El Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROOF repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 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. Ian:an employer tliat is pf•oviding wor•Irers'compensation insurance for rrty employees. Below is the policy and job site information. Insurance Company Name: LS'" Policy#or Self-ins.Lie.#: w✓J� 3 6 j Expiration Date: J_ ( /Of Job Site Address: /� �� City/State/Zip: V /I' ('v>r /%-`)r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify urn t 1 pains ncL nalties ofpeijufy that the information provided above is Jrue and correct. i �� Si nature: �.:=� " � � Date: Phone Official use only. Do not tvrite 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: loyees 'hire, more le Me Ouse 1 e i if .,COMMONWEALTH OF MAS AGH[JOUTS` o ze 4 BOARD-0 F fI-E TR.0 I,C I AN S 'ISSUES THE. FOLLOWING.•LIGENSE AS A R> G JOURNEYMRN =ELECTRhCLAN '`'jii ` lAU1S J OBR I ENRom 92B EA WN AUE I� INP5COTT MA 01907 12T0 t , 3