HomeMy WebLinkAboutWiring permit - Permits #13071 - 87 BELMONT STREET 1/20/2015 Date•. ...... 5... .. .......
NORTh
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ..•..........s.. ��, . : .�` .... ..... ..��4r �r.. .............•............
has permission to perform ................ ,..^ r
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wiring in the building of..... ........ • .. :....,.. `...........
at .� North Andover Mass.
Fee .. � ................Lic No. � ,. �_. ........ .� �.��'.:}c'f�•...'�,-~:...............
ELECTRICAL INSPECTOR,°
Check
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t✓Ominoneaitfe a��c f Official Use Only
aJJePartntent o�_fire�erriics3 Permit No_ i �(j -;7
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev_1/07j (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00
(PLEAS—F PRINT IN XK OR TYPE ALL MFOAMMTION) Date:
City or Town-of: ,A,161--,W ADo 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)_ ce",..--L,.<,�
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Vohs Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Coy letion Of the folimvin table may be waived by the Inspector of 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 KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o ergency g
KrIld. d. Battery Units
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 Alertin Devices
Tons g
No.of Waste Disposers Heat Pump Number JTons IKW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers SpacetArea Heating KW Local❑ Municipal El Other
Connection
Heating Appliances Security Systems:*
No.of Dryers g pp KW Na of Devices or Equivalent
No.of Water. KW No.of• o.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 Stark 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 0- BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: DidV 1 P L 1_G C:T R 1 GN1` GFJN TP t L, 1-Lc LIC.NO.:
Licensee: [i t. 14-466 rah Signature LIC.NO.: ( i4 Ci 1 �
(Ifapplicable,enter"exempt"in the license number line.) Bns.Tel.No..9 7 --+� ' ' •
Address: 1:i. lY►t�l,4 I- . r'�j t?�7tI } IsI1t:iI l�. IYt r�i R j3 Alt.Tel.No.:i I is -3 7
*Per M.G.L.c_147,s_57-61,security work requires Department 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 1 hereby waive this requirement. I am the(check one)❑owner ❑owner's a ern.
Owner/Agent PEIt1V UFEE.$
Signature Telephone No.
The Common wealth of Massach usetts
Department of InclustrialAccidents
=µ .. µ::':. ,
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" 10Office of Investigations
Z, 1 Congress Street, Suite 100
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Boston, MA 02114-2017
4.,..t,..:. ., 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.❑ I 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. F� 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]** I I.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers, ELECTRICAL CONTACTING
with no employees. [No workers' comp. insurance req.] 12g)ther
*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#1.
I am(in 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 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, and -th ins penalties of perjury that the information provided above i true and correct.
Signature:
Date: `±
Phone#: C138 0 /
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