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Home My WebLink AboutWiring Permit - Permits #12624-1 - 94 LYMAN ROAD 8/27/2015 Date..... ..... .`.� .... Nor+rM �2;,.•'�,�."tioo TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING 9a4QACHU9�4 6 This certifies that .. ....: .........1�� .�`. .F. ..... .................... has permission to perform ...... . ,:•• a1 wiring in the building of....... � --( �:�.....•. - � >........... t in North9"1A- nfA dover,Mass. at .......... .........Kq.' ......... pp Lic.No.k...f.. .. .Fee . ..... 1 ... .. .... °...................... ELECTRICAL INSPECTOR Check# dam Print Form '\ Ca�nmAnuieal o� a�3acinu lei Official Use Only Permit No. alJePartment o� ire�eruicee Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be performed in accordance with the Massachusetts ElectricaVCode 7Q,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOPIWATIO19 Date: ! _ City or Town of: /��iJ7f �/p+� To thector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) )lf"41% �L � Owner or Tenant C� c /CJC ,G! �, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No Q (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / 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: Com letion otthe olloivin table may be waived 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 Gt//fi o y— Generators KVA Na.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No.of Zones 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 g No.of Waste Disposers Heat Pump Number Tons IKW No.of Self-Contained Totals: ............ Detection/Alerting Devices r No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances K-W Security Systems:* 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: Attach additional detail ifdesired,or as required by the Inspector of Mres. Estimated Value of Electrical Work: (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 Q BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjuty,that Ili information on this p 1' d true and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature _ _ LIC.NO.: 14963 (Ifapplicable, enter "exempt"in the license number line.) Bus.Tel.No.,978-682-6262 Address: 87 BELMONT ST, NORTH ANDOVER, MA 01845 Alt.Tel.No.:978-375-5734 *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 FEE: $ 1/6 Signature Telephone No. ►o tl i i j ` I 1 , l S;� - �2 '� � y �� G% "°�a�, The Commonwealth ofMossachusetts �111,. Department of Industrial Accidents 0� � Office of Investigations I Congress Street, Suite 100 Roston,MA 02I14-2017 �= www nrass.gov1dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:DAVID ELECTRICAL CONTRACTING LLC Address:87 BELMONT ST City/State/Zip:NORTH ANDOVER, MA 01845 Phone#:978-682-6262 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with 8 employees (full and/ 5. ❑Retail or part-time).' 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. n Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity: [No workers' comp. insurance required] S• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** I 1 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other ELECTRICAL CONTACTING *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Beloiv is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/lip: OWATONNA, MN. 55060 Policy#or Self-ins. Lie. # 9353694 Expiration Date: MARCH 1, 2015 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 WORD ORDER and a tine of up to $250.00 a day agaiAin�s violator ,Be advised that a copy of this staternent may be forwarded to the Office of Investigations of the DIA france ;o ge verification. I do Hereby certify, uncle th pains r d enalties of perjury That the information provided bove is true and correct. Signature: Date: Phone Official use only. Do not-write in this area,to be completed by city or town official. City or Town: Per•mitfLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia