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Home My WebLink AboutWiring Permit - Permits #12743-1 - 222 BRIDGES LANE 10/5/2015 Date..... ...... ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING gBACHU Thiscertifies that .............I.......... ..................................................................... has permission to perform .......k ... ......... .................................................. ... ...... ... .... wiring in the building of... S r7,) .................... .....q.................................................................. Y2at .......... .I........ ..:.. .. I....... . ..... ...1..,.A....,.,�,..L.e............ ............ North Andover,Mass. Fee. . ..Lic.No. ......................... ..I 4. ELEcrRicAL INSPECTOR 1410 Chock# QQ Print Form l�otntnoruveaCt�o� a36ac�ztt�ei Official Use Only UVeCJePar�enent o��ire�eruices Permit No. BOARD OF FIRE PREVENTION REGULATIONS [Rev.Occupancy and Fee Checked 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 INFOR 4TION) Date: City or Town of: ,�VU�h� / 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) 2-Z2 ,66 —$ ems./` Owner or Tenant MI4hJE Mu 5722 Telephone No. Owner's Address 10 Is this permit in conjunction with a building permit? Yes No 0 (Check Appropriate Box) Purpose of Building . 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: ,..� Completion o the ollowin table maybe waived by the Inspector o JVires. 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 Above In- a o Emergency Lighting No,of Luminaires Swimming Pool rnd. ❑ rnd. ❑ 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 Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals ---� ._ ... KW___...........__. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW 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 ifdesired,or as required by the Inspector of 611ires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 ❑✓ BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties of petymy,that the information on this p lica ' n ' rue and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR Signature -----LIC.NO.: 14963 (Ifapplicable,enter"exempt"in the license number line.) Bus.Tel.No. 978-6$2-6262 Address: 87 BELMONT ST,NORTH ANDOVER, MA 01845 Alt.Tel.No.:978-375-5734 *Per M_G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 Signature Telephone No. PERMIT FEE: $ =— 0616,4/ /h sue/ /`0��// a .� %, The Commonwealth of Massach usetts Department of Industrial Accidents " Office of Investigations I Congress Street, Suite 100 E° Roston,MA 02114-2017 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.❑ 1 am a employer with $ employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bat/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑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' camp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 11"❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other ELECTRICAL CONTACTING *Any applicant that checks box 41 nwst 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 an employer that isproviding 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 " surance coverage verification. I do hereby certify, under lie p r� I l a es ofperjury that the information provided above is true and correct. Signature: Date: /0 /71 Phone 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 CIerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia „COMMONWEALTH OF MA,SS�CHUSETT_S ME m BOARD Of: � E -ECTRICIANS {SSUES THE F OLL04�1 NG L`I CENS REITERED, MASTER C I AN .ELECTRI i, 1a f S 1 l ; KRISOPHER D HF.GGAR 63� RIV.ERSIDE AVF }}� APT 2 FRA 01830 6773 HAVERHILL I 15G :4. t�7/3�/�6 32655 �,