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Home My WebLink AboutWiring Permit - Permits #13205 - 18 LYMAN ROAD 4/3/2015 Date ...� .... ................. �pp µpRr TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING �,8$ACHU`��t This certifies that Y has permission to perform '.. .q .:.. ......I.. wiringin the building of............................................................................................................... ' r '... ,North Andover Mass. at ........ c ... ................. ... IP �ic No. .. ........................� Fee. ..... .................... """""" LECTRICAL INS�CT Check Commonwealth of Massachusetts Official Use Only m Permit No. epart en of ,ire ices BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leand Fee lank)Checked s" (leave blank APPLICATION MIT TO PERFORM ELECTRICAL WORv All work to be performed in accordance with the Massachusetts Electrical Code(NIEC),527 CMR 12.00 (PLEASE PRINT ININIC OR TYPE ALL INFORMATION) Date: 4 , �, 14,E City or Town of: NORTH ANDOVER To the Inspector of 9 ires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) l L Lk okr Owner or Tenant Telephone No. B 7 ' Owner's Address S Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. ' ` Existing Service Amps 1' 1'2 olts 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: Completion o the following table may be waived by the Inspector` Wires. fs No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)fans No.of Total "2 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.Elo mergency ig tmg rnd, rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones__ No.of Detection and yµ No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained ....................................................... Totals: Detection/Alerting Devices � No.of Dishwashers Space/Area Heating IOW Local ElMunicipalConnection ❑ Other No.of Dryers Heating Appliances K.W Sec No.of Device s or E uivalent No.of Water No.of No.of Data Wiring: w;. Heaters KW Signs Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Mres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: LJ, J _ 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 cov9page 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 a d nalties ofpeilwy,that the information on tIRkwlication is true and complete. FIRM NA E: . a LIC.NO.: / 'A Licensee: , Signature LIC.NO.: (If applicable,enter "exernp in t e license number line) Bus.Tel.No.: 69 7( Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work 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. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT tEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the •, e permit application form to provide notice of installation of wiring shalt 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 M.G.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 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed- Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.} ❑ Inspectors Comme t Inspectors Signature: Date: FINAL INSPECTION: Pass 0 ; Failed Re-Inspection Required($.) ❑ Inspectors Comm Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts W Department oflndustrialAccidents d I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information cm. Please Print Le ibl Name (Business/Organization/Individual): ® " Address: ® , City/State/Zip: 1� Phone#: "L �S �7 Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 40 mployees(fiill and/or part-time).* 7. El New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, Remodeling any capacity. [No workers'comp.insurance required.] 9. Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q 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#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 providitig workers'competzsation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1 __ Policy#or Self-ins.Lic.#: Expiration Date: Vz Job Site Address:_ City/State/Zip: i qq�Il Attach a copy of the w ricers' qoolpensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL a 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 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. I do hereby c -tify under t epains ndpe alties ofpetjuty that the information provided above is true and cot-Feet. Signature: X 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4� ' B O•YI'Y,O� •` ® ® A�rH OF / � BQ��n� AS�ACHUS� UD Cr1 SS CE AS A THE �'l C A IS f KRVAN IS EIGTR/ £ t C NAMAS 92 2 , TOAD L V 10 1410 Op COMMONV1fEALT F MASAEHUSETTS BOARD'Of , C. EC'rR is I ANS 1 . ISSUES THE. FOLLOWING LICENSE: AS { ECiS1ERED. NiA >TGRELECTRI'CIAN BURR I S t PO SOX 492 HANIPSTEAD NH 03841 04�2 of n n 1