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Home My WebLink AboutWiring Permit - Permits #12299 - 30 LYONS WAY 4/23/2014 Date. .. E;. ? NORTH oo TOWN OF NORTH ANDOVER s PERMIT FOR WIRING �88ACHUgfc This certifies that ... ......................... �. i r has percussion to perform ............E <.:..... ..... ��..................................... wiring in the building of.................... °..... .. .. ...... ...................................... g a ��` ,Nq nth Andover,Mass t .... Fee.......:. .......... .....y. ....... ..gy.,.....f. . ELECTRICAL INSPECTOR Check# , C,nrnmohuuial _/ Official Use Only `7c7 n .d .paA.d.13.3.JQrvice6 Permit No. cc�� _ -- Occupancy and Fee Checked 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: LV I n/ I q City or Town of: QwzA 1, CNt,.>"y" 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) Owner or Tenant Telephone No.ct G%ot- 4600 Owner's Address Same as above Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building Dwelling 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: (�ep�gc d,�$ �� `�, 4Z� e: ,.� e�fy IIi Completion o the ollowin table m be waived b the Ins ector o g Tres. No.of Recessed Luminaires No.of Ceil.-Sus p•(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators IC�A No.of Luminaires SwimmingPool Above ❑ in ❑ o.o Emergency i gnung d. nd. Battery Units • No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners . of Detection an ' Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers ns Heat Pump Number Tons KW No.of Self-Contained P Totals: ............... Detection/Alerting Devices ► S ace/Area Heating KW Local❑ Municipal ❑ Other No.of Dishwashers P g Connection No.of Dryers Heating Appliances KW ec ystems: ry No No..of Devices or Equivalent o.of Water KW Signs of No.of Data Wiring: Heaters Si s Ballasts No.of Devices or Equivalent dromassa a Bathtubs No.of Motors Total HP Telecommunications Wirin No.Hg: y g No.of Devices or E uiva ens OTHER: Attach additional detail if desired,or as required by the Inspector of S. Estimated Value of Electrical Work: $650.00 (When required by municipal policy.) Work to Start: 4/F5 14 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Northeast Electrical Services INC. �, ' LIC.NO.:20782A Licensee: Daniel B. Kobus Signatur`T ,rn A J ::KO 4 LIC.NO.: (If applicable,enter "exempt"in the license number line)) / Bus.Tel.No.:508-966-74);7 Address: 40 N.Main Street P.O Box 361,Bellinqham,MA 02019 Alt.Tel.No.: 1 *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 norm y required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. I I The Commonwealth of Massachusetts Department oflndustrialAccidents Ok office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Northeast Electrical Services Address:40 N. Main Street, P.O Box 361 City/State/Zip:Bellingham, MA 02019 Phone#:508-966-7467 Are you an employer? Check the appropriate box: Type of project(required): 1.r7l I am a employer with 24 4, ❑ I am a general contractor.and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor�or partner- listed on the attached sheet. 7. ❑✓ Remodeling ship and have no employees These sub-contractors have g, � Demolition employees and have workers' working for me in any capacity. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.i required.] 5. ❑✓ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ q officers have exercised their 1 l.❑ Plumbing repairs or additions I am a homeowner doing all work myself.[No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp, insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Automatic Data Processing Insurance Agency,Inc. Policy#or Self-ins. Lic. #:NOW428117 Expiration Date:7/29/14 Job Site Address: City/State/Zip:No,AndDUUt&A/1- O M S Attacli.a copy of the workers' compensa ion 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 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. I do hereby certify under the pains a d penalties oLgerjury that the information provided above is true and correct. Si pure: .. _ 3: ... _- Date: . Phone#:50 - 66-7467 Offcial 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#: