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Home My WebLink AboutWiring Permit - Permits #12337 - 32 BANNAN DRIVE 5/6/2014 Date..... � . I Op NOR7p�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �88�cHU I x � This certifies that 5Jc— ......... ......... ......... ,�..... ......... ... ................. has permission to perform ... z f t __. ........f ........................................................... ............... f wiring in the building of,,,,; �;,��-` ...................................................... at }: '...::.:. ° orth Andover Mass.......... ......... .. ......., Fee........"..=,) ..............Lie.No.E.a. ... ...... . .......... . ......... .. . . ELECTMCAL IN E R Check# �� IJ , Z�1- Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ) 2r7 12.00 (PLEASE PNNTININK OR TYPE ALL INFORAM TION) Date: /N City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gi e of his or4er intention to performelectrical work described below, Location(Street&Number) vellsl ,-'eAAal ow Owner or Tenant N c �- Telephone No. ,z c 2 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service— Amps Volts Overhead[] UndgrdF] No.of Meters New Service Amps Volts Overhead n UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowin table may be waived by the Inspector of Wires. 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 No.of Luminaires Swimming pool Above Ei In- F1 N—o.—O-rEmergency Lighting y grnd. grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones No.of Sr No.of Detection and itches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Con d. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pump JNW........... No.of Self-Contained Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local n Municipal F1 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 En 111�Innt -OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of 1119rctripal Work: (When required by municipal policy.) Work to Start: _Inspections to be requested in accordance with MMC 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 covera i i force,and has exhibited proof of sa 0 to the permit issuing office. CHECK ONE: INSURANCE [;��BoND F❑I OTHER El (Specify:) 7 l certify, under the fs and ' !f.pen It iy,that the information on this ap�flcatlon is true and complete.VA Mpeiju plete. FIRMNAME A --CA-v I'( , LIC.NO.: 01 Licensee: hf�S\-tld4 C Signature LIC.NO.: (If applicable,ent ej the I* se nt!be I Bus.Tel.No. i�, ,irpt"in CT� C C) rA CAJr, Address: S(^Q1 UrIT .)4.) j� 51X , Alt.Tel.No.: *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)[I owner El owner's agent. Owner/Agent Signature Telephone No. &RMIT FEE: $ The Commonwealth of Massachusetts Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 UT www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ( , Please Print Le ibl Name(Business/OrganizatiorAndividual): Address: ,-�C r City/State/Zip: )V� CLck Phone (�- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a e er to with 4. El am a general contractor and I ' y ❑ * have hired the sub-contractors 6. New construction e tSyees(full and/or part-time). 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑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.❑Electrical repairs or additions 3.❑ 1 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.❑Roofrepairs insurance required.]r employees.[No workers' 1311 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 tfre doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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.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 requiredunder Section 25A of MGL e. 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 verific ion. I do hereby cert?o u er t ins and penalties o er'u that the information provided above isrue rd correct. Signature: Date: S C//2 Phone#• J ✓o�J 11 Official use only. Do not write in this area,to be completer)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#: COMMONWEALTH OF MASSACHIlSTTa `f BOARb'OF i !' E L.-F CTR I'C I A:NS I SSUES THE FOLLOWING L`1 CENSE ' iA5 A`.REG JOURN1w'YMAN :f LEG,TR VC I AN'i a, CHRISTOPHER JWHiTE; { '' Sjui 16 S CH°Al2L'E§ ST W V a $RADFORO.< MA o 1835 7516 j 1 1 61 ;B ... o / >1. 16 64397