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HomeMy WebLinkAboutWiring permit - Permits #11529 - 57 BERKELEY ROAD 4/18/2013 Date. ........ ::-..... . o�aoaroj TOWN OF NORTH ANDOVER '- PERMIT FOR WIRING CU This certifies that �r.�o� .�� �...F� .fir...: ... s. ........................................ has permission to perform ............... ........................................................... wiringin the building of............................................................................................................... at .. ...... �': � �.: .: ; : ......`. y �...................:.. North Andover,Mass. f Fee. .: ... ............Lic.No .. ' LEcrwcAL INSPECTOR,.* Check# _ l.oarawrurrealttz o c �cs�a s Official iisa Qaiy — �epae aunty re PelmitNo. l/572_0 BOARD OF FIRE PREVENTION REGULATIONS C �and Fee eked (scam blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be pen'mwd in amar+dam=wM thehf II 1 code CMR 1280 (P-L&4SEPRINTXNKORTZPE.IUW omIMT741V Date: r / City or Town of: I itcaz Tq the�ctor of FAu es: BY this appdicatian the tarcdersigaed gives notice of his or her intention to perfwm the electrical work described below_ focatian(Street&Number) z Owner orTenaut Telephone No. Owner's Address _ Is this permit in conjunction with a building permit? Yes No Purpose of Building (Check Appropriate Box) Utility Au*ot#adon No. RadstingService Amps / Service New Servi Vohs Overhead[ Iludgrd� No.of Meters ce Amps / Vohs . Overhead❑ Undgrd Q No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �}(� Ca leJion fire talon ' faue Way be UVM-ad the lnwmtoro Wires No.of Recessed Luminaires No.of Ceti.-Susp(Paddle)Fans - o.of ' _ Tsansiormers gyA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Fool�° © fey d- d- Ba o units No.Of Receptacle Outlets No.of Oil Burners ,ALARMS No.of Zones Initiating No.of Swrtches Na.of Gas:Unea o.of n anit DevicesNo.ofRauges No.of Air onti. Tons Na of Alec ring Devices No.of Waste Disposers / Z.o ons NO.o _ taiaed on1Ate� Devices us No.of Dishwashers / SpacdArea Heating JKW mrlelgal No.of Dryers Heating Apptrances Camrectdon D Other ISW No.of eview or iQate it o.of Wafer - o.of Heaters KW o.o _ Data Wiring s Ballasts No.ofDevices or Equivalent No-Hydromassage Bathtubs ]No_orMoturs Tntai HI' eaomma cations icingg- No.of Devices or atent OTHER: Mres. Attach ad&ional eras nquimd b detail ifdesired, y the Inspeaar of Estimated Value o€Electrical Worisr (When required by municipal Work to start: Policy.) moons too be requested in acmuh ice with AMC Ruk 10,and upon completion. MSURANG'l COVBBAGL: Unless waived by the owna.no permit for the PC& of electrical work issue unless the licensee provides proof of liabti ►insurance including"caompl�d��nr �Y undersigned crag that such cov eovoraga or ifs substantial equivalent. The emb'e is is fotre,and has exlibited proof ofsa m to the permit issuing office. CHECK ONE: 04SURANCE 5h BOND ❑ MUM [:] (S !", J l certify,under[ire pauwimd peauTties ofpffj+y,&W&e inforgualan as aPpF, is true and complete. FIRM NAi4iLr: OW! C+L i;&Tki CAL Ct�ti7 �}�C +-IGr "r LIC.NO.e Licensee: Ol;:i to [f 6 fa. rz Signature ,` " % K LIC.NO.: d'{I t,3 (IfaiPA=bkewer erarrpt`inr&I& weaumberlf - �-------------. Address-. i adtly'r'r art- -I7CYeI: r� I�I�` Bus.Ted.No.;_L7 r� e�� 'b 2�2 *Per hLG.L r;147,s_57-61,secatity work Aft:Tel.No.::,t -T 3- "T3� Depariwtof Public Safety"S"Incense: Lim No. OVMR'S INSURANCE WAIVER: I am aware that the Licensee does oat have he liability insurance coverage normally required by law. By my signattm below,I herebpwaive ft ngaimmenL I am the(check one []owned ❑owner's at. Owner/Agent Signature Telephone No. . �-_� � , ... 1 1� ®-� ,- Z 3 --�,,� ,. .:�1�: 1. ,. � e . �,, .. - � :35�.e: ... .. .. .. ... .. .. �I 1 4` 4Z. The Commonwealth ofHassachusett's PnntForm - Department o,f&dustrialAceMens Offibe' oflnvesdigationr .= 1 Congress Stree4 Suite 100 ` = Bosto,4M4 0211 4-2 01 7 WW spas&gavfdra Workers' Compensation Insurance Affidavit BWldersfContmetors/ElectricianslPlumbers Applicant Information Please Print Legibly Name(Bnsiriesooromizationnndividuai): DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST CityfSl /Lip. NORTH ANDOVER.MA_01845 Phone#.. 978-882-6262 Are you an employer?Check the appropriate bo= T' of Project 7 4_ I am a grad corrttad or and I Type p J (require ft I_�I am a employer with Q l employees(#uR arkWorpart4i me)_$ have hired the sub-contractors S- Q New construction 2-Q I am a sole ptvtTdclor or partner- listed on the shed sheet. 7. Q Remodeling ship and have no employees These sub-contractors bave g- o Demolition working for mein arty,capacity_ employees and have workers' 9 Q Em-lding addition INoworkers comp Lasumuce comp.insurance• M required-] 5-Q We are a corporation and its 1 QR]Electrical repairs or additions 3.Q law aborne owam doing an world officeits have exercised thee- l I.Q PIumbiry repairs or additions myself INN workers'comp_ right of0muption per MGL insuance required.]= c-152,§I(4),and we have no 12❑Roof regents employees_(No workers' 13.Q Otber comp-insurance redpzQecl_] Any applicant that checks box0I must also fill out the section below showing their workers'compensation policy inIarmarios. Homemmers who submit this affidavit indicating they are doing au wank and then hire outside contractors must-submit a new affidavit indicating such. *Contractors that check this boxmust attached an additional sheet showing the name ofthe sub-conhuctum and statewhetlw ornot those entities have eurptoyees. If thesub-contractors have employees,they on provide their workere eomp-podiev number. Iam as employer thatispmvidmg workers'compensation hzUu%nce forme employees Below is tliepofty audjobsHe information. Insurance company Name. THE HARTFORD Policy#or Self-ins-Lie. d#: 08 WEC C18293 Expiration Date; MARCH 1,201# Job Site Address: t CitylSta#e/2ip-. �f dx4r;t,- ,-r. Attach a copy of the workers'contpensa'on 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 ofcriminal penalties of a fore 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 oflup to$250.00 a day against the violator. Be advised that a copy of this statemeirt may be forwarded to the Office of Investigations of the DIA for iT ce Stage verification. ` t&atiheint orlrtm4ioa I do,tirrereby cerffy corder f pravufed a ve" Prue and conreet+ Phone 978-fr82 ial 081c use only_ Do notwrite hr tarts wr_ay io be completed by city ortown of'r�nL City or Town: PermitfUcense# lssmng Amtbtority(circle one): L Board of Health 2.Bnildimg Department 3 C.ity/fown Cleric el`Mec&i cal Iinspector �plumbing Iuspeetor 6-Other ContactPerson- Phoneft 'MM A, ISE a ISSUES THE ABOVE LICENSE TO: oEN�tIS 9' $QKBA f) C®RAL SF HAV-9RH I,LL MA 0 I- 30 13082 11 8 8$4w8q Fold,Then Detach Along All Perforations - _T i,