The URL can be used to link to this page

Home My WebLink AboutWiring permit - Permits #12333 - 100 BELMONT STREET 5/5/2014 i ..7 .PN Date ........ ..... .................. N�pTN °��,�•" .,�e TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU9E `.)a },.. .. �'4. .. �..:;. This certifies that .-,�. � has permission to perform 9 �yh wiring in the building of..r...:,L ......... ...... e. ........G ............ ...`...... ` ................. at t. Cy ,North Andover,Mass. Fee.U Lic No. .... ..... ......... .......,. ....,,... � ....�:� .�' .. vim. . ELECTRICAL INSPECroI, Check# - elinnwnwea&of MaMacliaJettd Official Use Only Permit No. Apartment ol3ire Service] 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR%�TION) Date: 7- 3, City or Town of: /)&f,t141 To the Inspector of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location(Street&Number)—,- a4- Owner or Tenant Ak r4m d Wer J e h 6 Q of Telephone No. Owner's Address '��l , Is this permit in conjuitTou with a building permit? Yes F� No F� (Check Appropriate Box) Purpose of Building qoe( Utility Authorization No. Existing Service_ Amps Volts Overhead n UndgrdF] No.of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 6,o Coinpletion gfibefiollowing table nicty 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 Ei of Emergency Eighting ,gi-nd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches No.of Detection- - and No.of Gas Burners IP— Initiating Devices No.of Ranges No.of Air Cond. , , 4-; No.of Alerting Devices 5P�- Total Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Total- ........... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local[:] Municipal F-1 Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: ' No.Hydromassage Bathtubs No.of Motors Total HP 77 No.of Devices or Equivalent -17 r- OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. - Estimated Value of Electrical Work: kl� (When required by municipal policy.) Work to Start: (6/4P le-;&-. ' 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 c?verage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE)EI—BOND F-1 OTHER El (Specify:) Cc I certify,under the pains and penalties of perjury,that lite ii iforinat* "on this(II)Pfication is true ad contlVete. _)C/ FIRM NAME: LIC. NO.: Licensee: Signatur LIC.NO.: (tfapplicable,et er Xe-," no in the license nuniber lin Bus.Tel.No.: 2'7,f- 1EY � Address: ❑UP X NA 624-W Alt.Tel.No.: 7? ��'-4 4 *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,I hereby waive this requirement. I am the(check one F-1 owner F-1 owner's a t. Owner/Agent PERMIT FEE: $ 1111 Signature Telephone No. [ 7) Cl� 1'e 0.0 �2 jVVCA, The Commonwealth of tV.lassachus'etts - Department oflndt(stri(itAccicients Office of Invesilgaflons 600 Washington Street Boston,.MA 02111 immmass gov/ciia Workers' Compensation Insurance Affidavit:Builders/ContractordElectricxans/�.'X�i n.�bers .A.uulxcant Worbaation Please Print Legibly Name(Businessiorgani'zation&dividual.): - a'/,I /4W .Address: City/State/Zip: ye?G� 1 ! Q 1 / Phone#: � �-57 Are your an emplcyer?Cheat the appropriate box: Type of project(required): 1.�( I am a employer with 4. ❑I am a general contractor and I 6. ❑New construction, employees(fall and/or pait time).* h.aveliitedthe sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7• �]Remodeling ' ship and`ltavo no.employees These sub-contractors have 8. [I Demolition working for me in.any capacity. workers'comp.insurance, 9• ❑Building addition [No Workers' comp.insurance 5. ❑ We are a corporation and its officers have exexcised.theix 10.[]Electrical repairs or additions required.] 3.[l I am a homeowner doing all work right of exemption per MGL ll.C(Plumbingxepairs or additions myself.[No workers' comp. c.152,§1(4),andwehaveno 12.Q Roofrepairs insurancere iced employees.[No workers,� .� 13.❑Other comp,insurance required.] xAny applicantthat checks box#1 mustalso fill outthe section below showingtheir workers'compensation policy information. Homeowners who submit Phis affidavit indicatingthey kre doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that cheekthis box must attached au additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information. X am an employer that is providing oviding workers'compensation insurance for my employees Below is tlaepolley and b site information. Insurance Company Name:. Policy#or S01-f ins.Lic.#: Expiration.Date: lob Site Address: � City%State/zip: Attach,a copy of the workers'compensation.polley declaration page(showing the policy number and expiration date). Failure to secure coverage as requireduuder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/or ones-year imprisonment,as well as civil penalties in the forth 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. X do Xaereby cent uricler ae p'ains and penaltie ofperjury that Me information provided alcove is true and correct. - Signature: Date: ' 2 1 Phone#: iU b4z - X Official use oidy. .Do not Write in dais area,to be completer)by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/-own.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - � - Contact Pers on: Phone 9: COMMONWEALTH OF M.: ASSAdj U rzTTS ELECTRICIANS ': . ISSUES 'THE FOLLOA LICENSE S �iG :JOURN£YMAN ELECTRfCIAN ] y fF JAI S M' LEONARO SR Z ` i DEXTER'..S METHUEN MA OI$44 5419 r 3$i <.E.. ,. O7/3:1 f 16 64441