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Home My WebLink AboutWiring permit - Permits #12581-1 - 27 BEACON HILL BOULEVARD 8/12/2015 - i Date.......j ...... 4 oRTH NORTH ANDOVER OWN OF T PERMIT FOR WIRING o ,BSACHUS� �9 pyg ................................. This certifies that ............... ....... � .. ...�.� s ya..• ..... . : has permission top erform rC ......................... .... wiling in the building of................... / ' �L r Mass at ........... ......... ws, _ ...... 1 7 pLINSPECTO Lic.NO. ELECTRIC Check# __ --�— � lei t, @.a Official U Commonwealth of Massachusetts se Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. i/07j (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfonned in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PPOWTININK 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 Telephone No. Owner's Address C d1,, H, Is this permit in'conjuncti ith a buildin permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building e i4A� Utility Authorization No. Existing Service /&(?./ Amps I&I I QW, Volts Overhead UndgrdE] No.of Meters New Service Amps Volts Overhead n Undgrd F] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingtable may be waived by the Inspector of Wires. o Total No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No, YA Transformers K No.of Luminalre Outlets No.of Hot Tubs Generators KVA NO No.of Luminaires swimming Pool Above Ei In- F1 NO-50-YEmergency Lighting grnd. grnd. ❑ Batter v Units No.of Receptacle Outlets No.of Oil Burners 'FIRE ALARMS INo. of Zones No.of Switches No. of Gas Burners No.of Detection and w. Initiating Devices No.of Ranges Na.of Air Cond. Tons Total No.of Alerting Devices No. of Waste Dis posers t Heat Pump ..........111CW No.of Self-Contained Totals: I ........... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑El Municipal F] Other Connection Sec No. D Heating Appliances IOW urit Systems:* No. of Dryers No.of Devi es 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 if desired, or as required by the Inspector of Wires, 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 BOND 0 OTHER F1 (Specify:) I certify, under thepains ty,that the hffibrination on this application is true and complete, FIRM NAMEtd LTC.NO.: Signature LTC.NO.:;�( 7 9-(,o Licensee: (If applicable, ente("exe,Wpt"in the license number line.) Bus.Tel.No.:�X- 20 4, Zaal��C045tf Alt.Tel.No.: Address: -/.6 P&4s S� 9 *Per M.G.L c. 147,s.57-6 1,security work requires Department o .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)[j owner [:1 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall 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,fine 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 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required{$.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signa re: Date: ROUGH INS CTION: Pass IN V Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: 4- Date: - —� FWAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts 01 Department of IndustrialAccidents _ I Congress Street,Suite 100 a, d F Soston,MA 02114 2017 >1'• � . d` www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builder,s/Contxactorsll lectxicians/k'lumbexs. TO BE FILED WITH THE FERM[TTING AUTHORITY. Please Print Legibly A licant Information Naxrle(Business/Orgariization/Individual): �- �— Address: City/State/Zip: CrJ<c Phone#' �'7� pp p Type of project(Tecluired); Are you an employer?Checktbe a ro date box: to full and/or part-time,).* 7. ❑New construction 1, am a employer with em P �'ees( 2. I am a sole proprietor or partnership and have no employees vrozking for mein $, Remo deliiig any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.0 I am a homeowner doing all workmysel£[No workers'comp.insurance required.]t 10❑Building addition 4..❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical or addition s ensure that all contractors either have workers'compensation insurance or are sole repairs employees. 12 Pt [] umbing repairs on additions proprietors with no 5.F]I am a general contractor and Ihave hired the sub-contractors listed onthe attached sheet. 11 Fj Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14 IOther 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicantthat 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 subunit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. R I am an employer that providingworkers'compensation insurance for my employees. Below is Me Po and job site licy is information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#:. City/State/Zip: Job Site Address: Attach a copy of the Workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as xequ. ed under MGL e. 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 certi ran-de *epains and p alties ofpef jury that the information provided ahave is true and correct. Date: Si ature: Phone#: n Offi at use only. Do not write in this area,to be completed by city or torvn official. Permit/License City or Town: # Issuing Authority(circle one): i 1.Board of health 2.Building Department 3.C4/Tovn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: Commonwealth of At as Lsetts Division of Registrati Board of Electric RYAN M E 45 ADA w rn -j m ! > LAWREN o Master Elec ' 'a 2172E-A 07/31/2016 License No., 068835 ExPiratiori Date: ,; Serial No.