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Home My WebLink AboutWiring permit - Permits #11839 - 217 BEAR HILL ROAD 9/9/2013 ( Date m IIII ............... µORT/y TOWN OF NORTH ANDOVER �:yy* PERMIT FOR WIRING B�gCHU9�t f This certifies that .....................�'E].: E has permission to performS� C w g of o e Cl—wiring in inthe building � � � �'o v ................ ................ 6"" ..... ........,North Andover,Mass. . Fee Lic.No c , ....... .. . F .,_- LE CAL IN P .................... ,'Check# ��r� Commonwealth of Massachusetts Official Use Only �A Department of Fire Services Permit No. 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: 9/9/13 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) 217 BEAR HILL ROAD Owner or Tenant DAVID KIBLER Telephone No. Owner's Address SAME Is this permit in conjunction with a building permit? Yes Ox No 0 BLDG PERMIT# Purpose of Building SINGLE FAMILY Utility Authorization No. N/A Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters �a New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters � "i. Number of Feeders and Ampacity , Location and Nature of Proposed Electrical Work: FLOAT AND RE-ATTACH METER FOR NEW SIDING.RE-INSTALL EXTERIOR_ LIGHT FIXTURES AND OUTLETS t Com letton of the olloivin table may be waived by the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil;Susp.(Paddle)Fans No.of Total Transformers KVA V l No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units `i 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 No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: I Detection/Alerting Devices 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 ICW 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: $500.00 (When required by municipal policy.) Work to Start: 9/9/13 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C n lFss waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is trite and complete. FIRM NAME: MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON,INC LIC.NO.: A10421 Licensee: MICHAEL KELLER Signature % ---- LIC.NO.: E25006 (Ifapplicable,enter"exempt"in the license number line) Bus.Tel.No.: 603-394-0117 Address: 27 WOODMAN ROAD,SOUTH HAMPTON,NH 03827 Alt.Tel.No.: 603-231-6068 *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"Licen LIC.NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signa- ture below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No. V .OMM®NWEALTH OF MASSACHUSETTS BQAS t3 ELECTRICIANS I TH E FOLLOWINf L10ENSE SSUES ' AS A ::RED JOURNEYMAN 'ELECTRIC BAR IQ MIC'HA.EL D KELLE>R lZ 27 WOODMAN RD S0 'HAMPTON NH 03827 3606 25006' E 0713>] 675 ® o •lY'ru3� The Commonwealth of Massachusetts Print Form Department of Industrial Accidents d„r ri 6 Office of Investigations m 600 Washington Street Boston,MA 021.11 wwminass,govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): MIKES ELECTRICAL SERVICE OF SOUTH HAMPTON, INC. Address: 27 WOODMAN ROAD City/State/Zip: SOUTH HAMPTON, NH 03827 Phone #: 603-231-6068 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 2 4. ® I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 workingfor me in an capacity. employees and have workers' y p �'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]f c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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. tContractors 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. TRAVELERS Insurance Company Name: Policy#or Self-ins.Lic.#:INUB0008592913 Expiration Date: JULY 16, 2014 Job Site Address:217 Bear Hill Road City/State/Zip:N.Andover, MA 01845 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 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 andpenalties of perjury that the information provided above is true and correct. Si nature: -. Date: September 9, 2013 Phone#: 3-231-606 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#: