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Home My WebLink AboutWiring Permit - Permits #12488-1 - 258 BRIDGES LANE 7/15/2015 Date......... ............... I p►ORT/.� TOWN OF NORTH ANDOVER PERMIT FOR WIRING BgACHUS� This certifies that fi .................. r :. ...... " ... ....... has permission to perform ..... ...............\..a ................................................................ wiring in the building of........ .L. .. ............................................................................ ' � at ..... `. . .: ..... .............. Andover,Mass. .... Fee Lic.No.�..�t�� ELECTRICAL INSPECTOR Check# 4 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (1paveblark) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 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. '2 c), Location(Street&Number)_ Q)f Owner or Tenant Telephone No. 2 1 S:n, 6,J: o 1, Owner's Address Is this permit in'conjunction with a building permit? Yes Non' (Check Appropriate Box) ,7 1 Purpose of Building (�(,!s; Utility Authorization No. Existing Service Lg��L Amps volts Overhead IF] Undgrd❑ No.of Meters New Service Amps Volts OverheadD Undgrd [I No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: "h12L Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Ceil.-Susp.(Paddle)Fans No. of Recessed Luminaires Transformers TVA No.of Luminaire Outlets No. of Hot Tubs Generators TCVA No.of Luminaires Swimming Pool Above o In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo, of Zones No. of Switches No.of Gas Burners No.of Detection and Total Initiating Devices No. of Ranges No.of Air Cond. Tn No.of Alerting Devices No. of Waste Disposers Heatpump Number ITons os KW No.of Self-Contained Totals: I ..........I .............. Detection/Alerting Devices No.of Dishwashers Space/Area Heating I(W Local El Munlc'PP' El Other Connection No. of Dryers Heating Appliances KW Security Systems:* -5— No.of Devices or Equivalent No. of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunic ations Wiring. No.Hydromassage Bathtubs No.of Motors Total IV No.of Devices or Equivalent OTHER: 0 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 'tt o (When required by municipal policy.) Work to Start: V - H -'\(" 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 ER BOND F] OTHER F] (Specify:) filify, iin(leiliepaiiisani 11eSwy,1hatih is application is frue and com 'a nforinafio�on this FIRM NAME-.t.A dpe 0fPeij ei LIC.NOplete,.: Licensee: Sign LTC.NO.:(If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: Address: A�,,,tA et%l',J 'A Alt.Tel.No.: *Per M.G.L c. 141,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)[I owner 0 owner's agent. Owner/Agent PrIRMITFEE.- Signature Telephone No. The Commonwealth of Massachusetts Department of fndustrialAccidents X Congress Street,Sr ite 100 =: F Boston,MA.02114 2017 www.rnass.gov/dia Y a'Ib sylt'4 Wolkexs'Compensationlnsuranca Affidavit:Builder/ContractOxS/Electricians/�lumbexs. TO BE FILED WITH THE 1?ERM1TT1NC 6 U"'1OR1T'Y. ' .,Please Print Le 'bl A �licant Information Name(Business/Orga*ation/Individual): Address: City/State/Zip: Phone 4: Are you an employer?Checicthie appropriate box: Type oftproject(required); i.Q I am a employer with employees(full and/or part time). 7. El Ne{v'constriictlon 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remo deliilg any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.E]I am a homeowner doing all work Myself[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ❑ ric 11. Electal repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 4 - � bin airs or additions proprietors with no employees. 12 L 1 PX g repairs 5.❑I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13TI Ro6f rep airs These sub-contractors have employees and have workers'comp.insurance.t 14.n Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MOL c. 152,§1(4),and we Have no employees.[No workers'comp.insurance required.] 'Any applicant that checks bbk 4l must also fill out the section below showing their workers'compensation policy information: i Homeowners who submii-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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that isprovidingworlcers'compensation insurancefor my employees. -Below is thepolicy anrlroli site information. Insurance Company Name: Policy#or Self ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL o.152,§25A is a criminal violation punishable by a Brie up to$1,500 00 and/or one-year imprisonment,as Well as civil penalties in the form of a STOP WORD ORDER.and a fine of up to $250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct Date: Si ature: Phone#: Official use only. Do not write ire this area,to be completed by city or torten official. City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: