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Home My WebLink AboutWiring Permit - Permits #11581 - 145 BRIDLE PATH 5/15/2013 Date................................... Of.T TOWN OF NORTH ANDOVER PERMIT FOR WIRING t.: �88ACH�1g�� e This certifies that "........ � ...... .................... has permission to perform ...:.e.. �4 ............... ............................ »g in the buildingof "' < L� orth Andover,Mass. at 4 � Lic.No.r eh 5e .... ............ Fee... ELECTRICAL INSPECTOR Check# ----- Commonwealth of Massachusetts O�,ic�ijalyUseOnly -- Department ®f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: /67/ 203 Cityor Town of: NORTH ANDOVER To the Ins e for of Wires: p By this application the undersigned gives notice of his F'jorr her mi tentio to perform the electrical work described below. Location(Street&Number) !q S 6,1-- (.e �-(,A 2 Owner or Tenant _ �«r-e-fu Telephone No. Owner's Address S P7�'9 Is this permit in conjunction witlh�a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building l Fir IV Utility Authorization No. Existing Service dt-9 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: iw;,-f f y ry 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 Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ElIn- ❑ o.o mergency ig ting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Tons Tot3 Z No.of Alerting Devices No. of Waste Disposers Heat Pump Number. Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No. of Dryers Heating Appliances KW Security Systems:Y Y No.of Devices or Equivalent No.of Water K,W No.of No.of Data Wiring: Heaters Signs Ballasts No,of Devices oar E uivalent dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: No.H Y g No.of Devices or Equivalent OTHER: / v�j dV Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of le trical Work: r (When required by municipal policy.) Work to Start: 1 s 1.3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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 F.V--r BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperyi fy,that the information on this application is true and complete. FIRM NAME: , Ph I/6 r;L t�- E til,c, J c' C LIC.NO.: Q 7 Licensee: X0 y ?h I d c,(,- Signature LTC.NO. (If applicable,enter "exempt"in the is nse number line.) Bus.Tel.No.:,7 / � t f�I Address: 3 Dew t,3 i 7 cu m, 414- 01;?cif. Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,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 FEE: $ Signature Telephone No. i The Commonwealth of Massachusetts " Department of IndustrialAcclknts Office of Investigations to 600 Washington Street Boston,MA 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: .3 Igo cu4V., 2 cQ ' City/State/Zip: tyi5 �, 64 Phone J` Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I 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 listed on the attached sheet. 7• ❑Remodeling 2. I am a sole proprietor or partner- ❑ ship and'haveno 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 (]Electrical repairs or additions required.] officers have exercised their 10. 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' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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 employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the paainnsand penalties of perjury that the information provided above is true and correct. Signature: ` )Gv Date: f J- . c /� Phone 4: f Zf 6 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#: kid I�CCJTS ISTCRF-D M A S F .-R ELrCTRILIAN , ISSUES THE ABOVE LiwENSE TO: D.B.A. PHZL BR ICK ELG:CTRT > CO.. Roy., W PHILBRICK SR C 3 ;LOWNS RD " , IiEsTFORD MA 95�i 9160 a n7f31f13 347 Y r r(