HomeMy WebLinkAboutWiring Permit - Permits #11985 - 50 BROOKVIEW DRIVE 11/4/2013 ......,.....
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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Thiscertifies that . .......�.....�..............�...�...........�..�.......�...�.............................................
E has permission to perform
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wiring in the building of.. ®... ..�.:. ' .........................................................
at ....... h ...... . r' ... ..krk.. ...u.........S ... . .............North Andover,Mass.
jFee.....�....................Lic No ................. .........:....... ...............................................................
ELECTRICAL INSPECTOR
Check# 'a "
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Loi�ssedewwad7s e�7 ?adsaefs.esdfe Cffic ai useOafy
c ,� Pemuit NO.
d� s��irsric�d
BOARD OF FIRE PREVENTION REGULATIONS muiF b
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Afl wo&to berrimed in aaomla= Cod=13,1
iZ.ita
(PIMSEPR�I'1'IV&W OR TYPEffZ NFOU"27 A9 Date:,
City ar Taw&of: N o�- f4 ti&O v" To the.hr wsa tor'of it -w:
By this aphofion the cd gives notice of his or her tD pew ate I wic dnmi)od below
Location(Street& 50 Raooky te.w 't>R.\v e
oTwaerorTeaant Sv sa►��a �vaNae\�s� A Tde)la:aeNo.
Owser'sAddress I;SQmf )
Is dtfs pmoit is c of whit a buf diikg perasrt? Yes ❑ Ne jo . (Ch9*Appropriate Jkx)
rurpose of ceding l7Wt't I l t1A ut ay Aat whatien No.
.Ming Service Amps I Volts Overhftd Q undad Q Ne.of meters
New SWWke, Amps / Vas Oymbead Fiaagrd❑ Na of.Meters
Number of Feedm and Ampadiy
Location mdNataereot Proposed tWerb
Covwkmn-ofthe t+rble be the of wires.
Na efReoessed Lummbaft4m No.efCem-Sasp.Owwo Fam NO.
of Tom
Trsasfivaters KVA
O.efL4un1n1kire0nt1M No.efHet Tubs Geeeraturs BVA
a ofLsmminalees SWIMIKf2g Pod Above Q _ Qzmd. mad, BatteryUnks
ufRec*tmdeE» Noefofiftmers ALARMS Fo Ee:r.
NO.of S�, cites NeofGasftmers NO.
ofBetecdea and
N, 4)6 otRauges. NoofAirCooL TomafAlerdng Dedem
ElemtN.of W25WD s Tom: Namber D
a.of Disltwwhas 1 Spa WArea Seathig lCW Local❑Comet Q Oda'
No.of Dryers HesdagAppliancesKW Secaray
Na at Equivalent
Ne.—Gfwuter KW mot No.of Data
He"m Bsgasts Na of Deviees or eat
ofMetors Total HP s
o.SydroatassageBa�bs Na.efDovfoesor niv�eat
.ivach adftouat deter fd or as ragrra¢d bytTee Zqp
Esd edValueof Wad: for o° (Whm xequRed Wm Polk9•)
Want.to Stut 1 lnVedians to bexepesbed in amosdauce vh&NEC Rile ia,and upon comgi .
L*i' RAC G£: Unim vmivei by ffie owaz4 no p=k f�the patforn:a=of l Vm&may issue unless
the l eLWe Provides Proof of�l ee "gyp e coverage mifs till� The
undersigned cep that such covemp is in farce,audhas gxhsibited proof of same to to per=issmg Office.
1.'HECK ONE: 24Si3RANCE 1 BOND Q OTHM Q (Spe9y:)
l ,gx&r*epat+esWdpmeMmofP ,thatdtu hym lox on istint and�
FUN NAME: m LIC.NR:
s LIGNQ:3 I l55 E
'kPec M G.L.a 147,s.57-61,secassty
vwe&teq*m:DeP&emea 1ic Safely"S" mmm Lis.No.
pplik'EB'S DjSU ANtz WAIVER: lam awarethatthe Licensee doo not kaw the liabift wveuV ua=altp
repaired by law. $y say �Y b�lsy waive his went 1 ssn she(eheCic one o�ser oWaer's t.
l Tel"hone No. [PEMME.-I 5,
ware
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Of ee of Invesdgations
I Congress Stree4 Suite 100
Boston,MA 02114 2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information C Please Print Legibly
Name (Business/organization/Individual): NO rh CAra l G I-ectZ-1 4L Si RUl c Fs /
Address: `7 Dug,41 A I S P O Roy 3 6
City/State/Zip: 8falW&A A Al �A?Phone#: - Mj -
Are you an employer?Check the appropriate bog: Type of project(required):
1X I am a employer with 4. n I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. WRemodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. Q Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10,KElectdcal repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152,§1(4),and we have no
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.
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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /y/ 44 k
Policy#or Self-ins.Lie.#: O v/C y � A/3 hj Expiration Date: a-!p
!
Job Site Address: 3Y0OtGytew h�►�' _City/State/Zip:klpoAn(YM MA oIS415
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 ma#be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under,th ahu a perjury the information provided above is true and correct.
Signature: 6 Date: riQ 1 '
Phone#: �D�� ! 7y�
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#:
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