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HomeMy WebLinkAboutWiring permit - Permits #13266 - 231 BEAR HILL ROAD 4/28/2015 p Date.... ............... ....... OF 40RTH� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING Y owe• ..••..... 88ACHUS�C i This certifies that ..............................t:................... has permission to perform ..... ` ......t..........,..................................... ......... wiring in the building of ..............rass.. r A t „„ North Andover,M at t.... ........... t x............ ....Lic. No ?.............. . ........... .. ....... ELECTRICAL INSPECTOR Check# r r � - Commonwealth of Massachusetts Official Only icialUse a Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) 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 cy her intention tp perform the electrical work described below. Location(Street&Number)_ 3/; Owner or Tenant N(L P6ri e{ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building r!n t}It 1 r�_ rn i,,1r Utility Authorization No. Existing Service aC O Amps 0/ 120 Volts Overhead Q 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: `3,qS ,iy�,,�" Add j i�e,c�p`i`�s -,J Completion of the olloi-in table inay be ivaivedhy the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators ICVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 6 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 KW No.of Self-Contained Totals: """"""""""""""""""" ..""""" Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: 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://2&-2er'5' Inspections to be requested in accordance with MEC Rule 10,and upon completion. +f 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 er e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE co[BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and coriplete. FIRM NAME: ,+ 9 ab.S ,(',fee j2 i LIC.NO.: 12,Y22 Licensee: ITfZAS Signature '-2 E:5 LIC.NO.: .31s2`%6 (IfappZicable, tg 'exempt444V the li nse number line.) i Bus.Tel.No.r� Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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: $-tom j Signature Telephone No. • o .4aLnI.,.L.Li1.q'(,.1C'"t�_a'eft.�C^.{+L'pi�1�i.'1.fF'�. T N(0). /�'-'{�. •(S']J'p,f(`( O AL x.x�o�ro�.x�r�PJ�cT�o�r; •,• .. _ . �'�ssecl-"[ � �+alled-•[ ] �e-auspectzon xegnzxec7($50A0)•-� � �izspectoxs'ea efts: - (fnspectoxs'S a Xe••no initials) _ pate assed- � ) Failed --.( � xWnuspection required($50.00)-•[ xns,ectoxs'comments: - (Gwectors'signature•-no Initials) Jute 3.UMAR G•RODM)USPECTZON. Passed= +axzecl- [ ) ate xns�ectzon xegt�ixecT($50.00) [ ] nspectoxs'coxabzents: (Itispectoxs}sIgnataxe-•no initials) pate 4.)TOOPEMON'--RER.'VT!CE: Passed-- Re•.Inspection required($50.00)-•( � Inspeetbrs'coRllYnmis: (Inspectors'Szgttgture.Sao Initials) Date 5,INS EMON-•OTHER:' Passed—[ I Re inspection reqvixed($50.00)--[ � Inspectors'comments: �ectoxs' Ignat�ue no Inials} Date D 0OR TAG$"R TO BE MMED OUT AND YEP'T ON RITE M THE AREA.TO 33E WSPECTED 19 NOT ACCESSIBLE AND.A RE WRPECTZON•OF$50.00 IN TO BE CHA�2 GED. The Commonwealth of Massachusetts z Department of lndustrialAccidents i d 1 Congress Sheet,Suite 100 F Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name(Business/Organization/Individual): Al:!,O �- ` Address: 2— � ;3r Ilan c�� ,M �- C/82 7 �ti� t9�t, City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(Tequired): l.❑I am a employerwith employees(full and/or part-time).* 7. New construction 2•P1 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t �<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.Q Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. Roof repairs • These sub-contractors have employees and have workers'comp.insurance.$ 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#1 must also fill out the section below showing their workers'compensation policy information. 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. lam an employer ttiat is providing ivor•Icers'compensation insurance for•my employees.'Belory is the policy and job site information. Insurance Company Name: 722,4J rLrS 7;S Policy#or Self-ins,Lie.#: 44 6 3`3 76%C C Y c7 Expiration Date: ,/S 4� Job Site Address: 2 3 1 3�"r �� rZ d City/State/Zip: � AAA /,,-c(- Attach a copy of the workers'compepsation 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 Pine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance _coverage verification. I do hereby certify under the pains andpenaIt' s ofperjury that the information provided above is true and correct. Sig nature• /1 7 Date: 15 Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH OF MA$SACHI'S TTS ELi CJ At. 1 is T £ FOLLOWINdil C BASE A } REGI E ED MASTER ELECTRICt#N C1 �b ELECTRUc I Cf`R PO TR t EZ 5 2. PINE D►� E AVENUE w ' J O1 ER1Ci� fiA 018217 dos 1 Mao 3�6 .. ... .. . ....... ;COMMONWEALTH OF MASSACHt1SETT gOAl3D OF. ELECTRICIANS ISSUES;;.THE iiFOLLOWI.NG >'L'I`CENSE IN A5 A RAG JOURNEYMAN ELECTRIGIA ;F BRUd R PO1TRAS N.. 92 PINEDALE AVETILu B III GA MA 61821 631'6 315ME,. of/ l/lb 56703 j • .. a