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Home My WebLink AboutWiring permit - Permits #12845 - 90 BERKELEY ROAD 11/9/2015 Date......P °. � .............. OF ptORTF�, o?:' :�•�°om TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU9�t y This certifies that ............. , .. .......6.......... :.�..� ......... �:. ........... y l9 has permission to perform .,r ;"� �• 6 ... ,. ............ ,,•, -. . ...p ................................................... wiring in-the building of.... •..at ..;. .. ,;North Andover,Mass. Fee.. Lic. No c &, ,94� t ..n.... ELECTRICAL INSPECTOR Check#` 'L C � �yA Print Form tfommonwea&of Wamackajettz Official Use Only Apartment of Jiro Service Permit No. e BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 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 INFORMATION) Date: november 9 2015 City or Town of: north andover 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) 90 berkly road Owner or Tenant jeff kingh Telephone No. 2039121092 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building dwelling Utility Authorization No. Existing Service Amps / Volts Overhead ❑ 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: one receptacle outlet for gas insert Com letion o the ollowin table maybe 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- Elo,o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets 1 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/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.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: $400.00 (When required by municipal policy.) Work to Start: 11/9/15 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 o s e to the permit issuing office. CHECK ONE: INSURANCE R BOND ❑ OTHER [I (Specif':) I certify,under the pains and penalties of perjury,that the informati',in p ds application is trite and complete. FIRM NAME: lance macinnis electric /�l `•' LIC.NO.:21217a Licensee: lance macinnis Signature � / „/ LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:5087260802 Address: 12 locust street middleton ma 01949 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Depa ent 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)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): lance macinnis electric Address: 12 locust street City/State/Zip: I Middleton ma 01949 Phone #: C 5087260802 Are you an employer? Check the appropriate box: Type of project(required): 1.F1 I am a employer with 1 4. U I am a general contractor and I 6. ®New construction employees (full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t 7• rl Remodeling ship and have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. EJ We are a corporation and its 10.RE Electrical repairs or additions required.] officers have exercised their 3.E3 I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. Roof repairs insurance required.] t employees. [No workers' 13.rl Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an etttployer that is providing worker,'cotrapensation instrance for my employees. Below is the policy and job site in formation. Insurance Company Name: 1,the hartford Policy#or Self-ins. Lic. #: 76wegpz4981 Expiration Date: C 1/1/16 90 berkly road Job Site Address: City/State/Zip: I north andover ma :] 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 d against t iolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the IA for ' sura ce coverage verification. I do herebyr if r tiler th pains ar d penalties of perjury that the information provided above is true and correct. Z11/9/15 Sr nature. Date: - --- -- Phone#: i 08 608 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#: COMMONWEACTHOF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED ASTER ELECT -� LAKE G MAC I NN I S 12 LOCUST STUl M` MI DDLI:TCN MA r 1` 49-1 06 � �