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Home My WebLink AboutWiring Permit - Permits #13254 - 82 LISA LANE 4/23/2015 Date....d.:::...:�.. NORTf4 TOWN OF NORTH ANDOVER PERMIT FOR WIRING g�ACHUy� This certifies that ..: has permission to perform ...: . t....... . ....... H wrongin the building of........ ..... ' .......:::..:............................................................................ at ... s `. ..:..:.. ,North Andover,Mass. . .. ........Fee......' Lie.No. . ...... .... ............. ............. .. ELECTRICAL INSPE, OR Check# `s Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.—1,1-271 91 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 ),527 CNI Electrical Code(ME R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)TION) Date: (�L 7 3 City or Town of. NORTH ANDOVER To the Ins'pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below, Location(Street& Number) -Ownei or-Tenant V, t Telephone No. 60 3 V ,iI2.2 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 2 12CL Amps 0012 72 0 Volts Overhead [D" UndgrdE:1 No.of Meters New Service Amps Volts Overhead E] Undgrd F] No.of Meters Number of Feeders and Ampacity Locqtion and Nature of Proposed Electrical Work: a a 't6fiblloiring table ma be ivaived by the Inspector of,Wires. No.of Recessed Luminaires No.of Ceil.-Sus (Paddle)Fans No.of Total p Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Poi n_ No. of E mergency Lighting find. find. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones r "1_1 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 Heat Pump Number r. Tons KW No.of Self-Contained No.of Waste Disposers Totals: I ........... Detection/Alerting Devices Ej Municipal No.of Dishwashers Space/Area Heating KW Local Connection [:] Other No.of Dryers Heating Appliances KW Security Systems:* N I o.of No.of No.of bevices or E_quivalent No.of Water KW Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: I No.of Devices or Eguivalent OTHER: Attach additional detail rfdesired,or as requh-ed by the Inspector of JVii-es. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /S1 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 R BOND F1 OTHER F] (Specify:) I certify,under the pains andpenalties ofpetjtvy,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Signature LIC. NO.: (1faPplicable entei, ewin 1"111th license nanbef'filie) Bus.Tel.No.: Address: Alt.Tel.No.: *Per M.G.L c. 147,s. 57-6 1,security work tequires Department of Pu6lic 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) El owner [I owner's agent. Owner/Agent Signature Telephone No. PERMIT The Commonwealth of Massach usetts DepaNnient of Industrial Accidents tl 1 Congress Street, Suite 100 Boston, MA 02114-2017 wilviv.Mass.govIelia Workers'Compensation Insurance Affidavit: Builders/Coiiti-actoi-s/Electi-iciatis/Pitimbet-s. TO 13E FILED WITH T11E PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: Phone City/State/Zip �44 Ph Are you an employer?Check the appropriate box: Type of project(required): 1.F]I am a employer with employees(full and/or part-time). 7. ❑New construction 2. am, sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition In I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4,[-]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L[j Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.n l 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'coal[).insuranceJ 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] L *Any applicant that checks box#I must also fill out the section below showing their workers'compcnsatio�i policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors Must Submit a new affidavit indicating such. tContractors that check this box must attached all 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 atr employer that is providing Ivoi•Icers'compensation ifrsctrance for•my employees. Beloit)is the policy and job site ill ration. !foin Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date,: Job Site Address: (f(� City/State/Zip: e 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 tip 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l(lohei-ebycei-tifyttiidg).!th,e;,paiti5-aiiV. lialtiesoj'lleijui- that the inforniation provided above is, rue an(l correct. Si nature: Date: hd l2-3 Phope_#.- 2t� iU.2!�4 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#: ,:.COMMONWEALTH OF MASSAGHUSETTS. f'< BOARD'OF ELECTRICIANS I ISSUES THE' FOLLOWING`'LICENSE I k AS A REG UOURNEYMAN..ELECTRI>GIAN S z J OBR I EN �28 EASTMAIV AVER n `WAMPSCOTT MA 01907 12T0 F ,rr r 0j"1l1� fL;10,1 e ff