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HomeMy WebLinkAboutWiring Permit - Permits #13174 - 81 LYONS WAY 3/23/2015 jDate r ... ................ OF NOAT�y 1 ova:'.���= �'•�°om TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHUS� This certifies that has permission to perform / W b wiring in the building of . ........... at ¢ j F ,?...`::... North Andover,Mass. Fe ... ..............Lic.No f .......4�j. ....... ......... t C ........ I ELECTRICAL INSPECTOR i ^heck# �1 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. � 7I 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 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) Owner or Tenant ��� ;,.a Telephone No. Owner's Address S �z Is this permit in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Purpose of Building❑' 2a. /- � ,,q,;, f,/ Utility Authorization No. Existing Service 2 0 0 Amps -Z%f/ 2/O�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: CCs �, � -��� d 2 reC� Can letion of the followin table inay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total 1 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators 12769 KVA ❑ No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I 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 KW No.of Self-Contained Totals: "''""".............. Detection/Alerting Devices l� No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other "❑ Connection No.of Dryers Heating Appliances KW 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 E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of 11"ires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1�,1s"Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: 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 ofperjury,that the information on this application is true and complete. FIRM NAME: �j,''(�i. N/ 3 '� d LIC.NO.: Licensee: 71�' L� �>/ t=�, .t,� Signature `. �'�_ � LIC.NO.: �,5 (If applicable, enter "exeni t"in the license number line.) Bus.Tel.No.: Address: Alt.Tel.No.: `Per M.G.L c. 147,s. 57-61,security work requires Departmen 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 a ent. Owner/Agent PERMIT FEE. $ �lQ❑ Signature Telephone No. G co Z +I (-,�V The Commonwealth of Massachusetts f Department of IndustrialAccidents - 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): 4�1'6 Z2L4,6 Address: ' City/State/Zip: &e 1 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 119°" am a employer with employees(fall and/or part-time).* 7. ❑New construction 2.r]1 am a sole proprietor or partnership and have no employees working for me in 8. C]Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will �r ensure that all contractors either have workers'compensation insurance or are sole 11. ,iectrical repairs or additions proprietors with no employees. 12.E]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 4l must also fill out the section below showing their workers'compensation policy infonnation. f 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: Js . �,1 `"z" C Policy#or Self-ins.Lic.#: Expiration Date: / Job Site Address: ro f""' r 4.,... City/State/Zip: " t 1 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 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 certify under the pains and penalties ofperjwy that the information provided above is true and correct, rture: Date: qhco. Phone#; • ...0-0 K 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#: - 312312015 Division of Professional Ucenmure:License Search . T�,Offlcia|Wa.bsite of the Office of CunoLfffler Affairs and BUSineno Regulation(OCABR) - ��^ ~ ~��K� x�� �� ~��8���U 8 ~�������K���} _r^ ~ ~~~^ —^ ^ ^ ^-~~~`~~~~ ~ ~�^ mass.00v Mass.Gov Home State Agencies r-Zmpics ")SERVICES Home Division of Professional Licensure Check a License Check A Professional License Locate a I.Acensed Professional By the Division of Professional Licensure OnEne Address Change Contact the Agency LICENSEE Name: MICHAEL J. FORD REFERENCES& 14EW SEAI�CH Disclaimer Regarding Website License Searches Licensing Board: ELECTRICIANS Glossary v/ License Status ucenseTypc' JOURNEYMAN ELECTRICIAN Codaa ' TYPE CLASS: E More- UcenseNumben 23768 Status: CURRENT ' Expiration Date: 7/31/2016 Issue Date: 4/25/1977 Exam Date: 4/5/1977 School: This web site displays disciplinary actions dating back to199l This license has had nn disciplinary actions taken during this time. _ The page above has been generated by the Division of Professional Ucensueweb ` server on Monday,March 23.2O15ut9:OO:52 AM. @2OO7'2011 Commonwealth of Mass aohuneits Site Policies Contact Us � ���EL tn ' '. ~ -~-.