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Home My WebLink AboutWiring Permit - Permits #12614 - 190 BRIDGES LANE 8/15/2014 r. ..Date.. �. ......... °�HORrHgtic TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8'®CHUg� This certifies that ., < x t s . has permission to perform ....... .E� � ': ........ wiring in the building of,...,.. P at �....... �: .......... .:! ............... N h And over,Mass. Fee.... .:.:...................Lie.No ....�.k .. .,... ................ �'. . .......... . .. ................. .. ELECTRICAL INSPECTOR �r Check# G } \ Commonwealth of Massachusetts Official ��Use Only Department ®f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank �N 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: $=/s=Jo1 5� 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) k2).„AQ r c Lc..,- Owner or Tenant C is rr, scL#Vnt Telephone No. 79sz- Owner's Address .Sj r� . Is this permit in conjunction with a building permit? Yes [�J— No ❑ (Check Appropriate Box) Purpose of Building L�Azt 1I3 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: �i1� �i2. ��• �t j� �_ -3 1 J Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires a Swimming Pool Above ❑ In- Elo.-OTTmergency Lig tmg rnd. grnd. 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 CrJ Initiating Devices No.of Ran es No.of Air Cond. Total No.of Alerting Devices g Tons No. of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained p Totals: ""I ""..........""'....................... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection uritNo. of Dryers Heating Appliances KW Sec No.o DevSysteices or Equivalent No.of Water KW No.of No.of Data Wiring: Beaters Signs - Ballasts No.of Devices or E uivalent No.H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated'Value of Electrical Work: t�W.Gy (When required by municipal policy.) Work to Start: t . _Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: 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 -,BOND ❑ OTHER ❑ (Specify:) I certify, itnder the pains and penalties of perjury,drat the info rniation on this application is true and complete. FIRM NAME: . - LIC.NO.:�— Licensee: Signature LTC.NO.: G• (If applicable,enter "exempt"in the license number line) Bus.Tel.No.:��'�'�/' Address: .0/4E 0 3F4-S Alt.Tel.No.:(zQ Jv/-/.P'71- *Per M.G.L c. f471,�t-s^rT-64,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)❑owner ❑owner's agent. Owner/Agent PERMIT Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,thi; permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be frlcd�. on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32, an electrical pen-nit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing art hutorriati0four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: *** te:Ieapply for new permit El r z.; n Permit ExiLension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection'Required($.) ❑ Inspectors Comments: Inspectors Sighlu`re`:' � `� `a_��:r L . , , . Date: 'T.r., ._ ,.x r..•r i „ra a ,,. ...-*t '."w: ` ...�:-i,1, 'S�'to°. e �s,' - . SERVICE INSPECTION: Pass Failed Re-Inspection.Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: Y: PARTIAL ROUGH INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: r ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comm nts: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 ��` o- Failed 0 Re-I,nspect4?n Required($;),_❑ Inspectors CommeriPs: r t. YI.Pt'tit ,a, ,�• - ', '•)? Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustrlalAccidents 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 Le0bly Name(Business/Organization/tndividual): JaIr�1�/�u— Address:-6 T City/State/Zip: H a Phone#: 611.6/- & 7e-' Are you an employer?Check the appropriate box: Type of project(required): 1.HI am a employer with�_ 4• ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ 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' 1311 Other 4 comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lain an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name:. Policy or Self-ins.Lie.#: Expiration Date: Job Site Address: zqj:f? P—r /-Q.+.d City/State/Zip:'a,GL,�,,�, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert o under the pains and penalties ofperjury that the information provided t.above is true and correct Signature: Date O - l / Phone#• S/ :;)4_2 k/FT 7G Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0 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#: o r :COMMONWEALTH OF M, SACHUSETTS BOARD OF )i LECTRI Cl ANS ISSKS .THE FOLLOWING 1ICENSE ' A A REG JOURNEYMAN ,ELECTRICIAW I ,Q MICHAEL A' BEAULIEU 6 TUXBUR- ROAD` $ pLAIS10w NH 03865-2238 28566 .E 07/3�/16 62147z"