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Home My WebLink AboutWiring permit - Permits #12332 - 457 BEAR HILL ROAD 5/5/2014 Date ; ............... oQ TOWN OF NORTH ANDOVER I ? p PERMIT FOR WIRING �,88ACHUg� r. b G .. This certifies that ...... ... t l ............ b... � k f� ...... ................................ ....•.. has perm perform to 4 ;t,�$ 1 ....................... wiring in the building of... .. North Andover,Mass. ..... v. Lic.No ii .�. ,....�.. I ............ ELECTRT^AL INSPECT R 41 Check# -- ---- — _ - '`� 6 � (f1mm-oiuveaA4 ol M Official U OnlyamacAudotb Permit No. 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(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE, ALL INFORMATION) Date: City or Town-of. _ A164 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) 1-6a- A--� Owner or Tenant /a/lk Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead F-1 Undgrd n No.of Meters New Set-vice Amps Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: g2m thefollowing able may he waived by the Inspector o f Wires. _21etion of the No.of No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above No.—Of Emergency Lighting D grnd. rnd. BatteKy Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches No.of Gas Burners of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump No.of Self-Contained Totals: Detection/Alerting Devices Local E] Municipal No.of Dishwashers Space/Area Heating KW ca Connection El Other No.of Dryers Heating Appliances KW Security ste No.of evies or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent (0 OTHER: Attach additional detail ifdesired,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 F-1 BOND El OTHER F-1 (Specify:) I certify,under the pains and penalties ofpetjmy,that the information on this 11P a I IC ii I tioiv iti-iieaiiri complete. FIRM NAME: Dj\\! I P E L T R 1 C/A 1-- CO" 1-R AC I LIC.NO.: Licensee: DA*\/([> k/4664R Signature Ive-11a LIC.NO.: 3 (If applicable,enter "exempt"in the license number ber line.) Bus.Tel.No. 0t Address: W7 -- Ljn j4 0 '1- 67- N M M ijiIivvvink III A. o/a Alt.Tel.No.:'-11S -.37 5---)-Z5tf *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety'IS"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)F]owner n owner's agent. Owner/Azent Signatur�- Telephone No. PERMIT FEE: $ �� h `�=�-�� .. The Commonwealth of Massachusetts Department of IntlustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information. Please Print Legibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST City/State/Zip: NORTH ANDOVER, MA 01845 Phone #:978-682-6262 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ 1 am a employer with 8 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]" 11.❑ Health Care ,4.❑ We are a non-profit organization, staffed by volunteers, ELECTRICAL CONTACTING with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. *,*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy# or Self-ins. Lic. # 9353694 Expiration.Date: MARCH 1, 2015 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 a STOP WORK ORDER and a fine of up to $250.00 a day against the 4ce Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insuverag verif ation. I do hereby certify, under the p iris r e l e I of perjury that the information provided a ve is t ue and correct. Si,nature: Date: I V-1 -el-j ( Phone#: Z—Zd � � Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia I .GOMMONWEAI.TH>OF 1VI�$�,p►�HUSETT;S • • • a , , B3AI�Gk x � CIN1'C�3ANS ISSUES THE FO'LLOWI�tG L1ENSE pSEr 1OURNEYMA LECT cc lZ AE�J�1:15 B BOMBARD E 60 W MAEat11 LL MA o1830 2108 ! T30821 0l/31/lb 395? o .