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Home My WebLink AboutWiring Permit - Permits #12318 - 52 BANNAN DRIVE 4/28/2014 Date., ......................... Of"ORrh • . TOWN OF NORTH ANDOVER * ' - * PERMIT FOR WRING I * i aBgCHue�� I i $ F � This certifies that � �� - ... .. .... ....: .:: ., has e p rmission to perform ''i ... .... ........................... ................................................. wiring in the building of r at �........... ��i b ................................... North Andover Mass i . Fee � ... Lic.No J c 3 ...... ...,.[.. ��...ELEC'i'ICgI. �,� f� w...... INSPECl'OR J ! Check# Y.' , g�•r u e��! .. f 5 3 rs•;.� /yam Official�Use 1—y — BOARD ,teneonw a� k�ac�it�a� '/ Permit No.Occupancy and Fee Checked OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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 W INK OR TYPE ALL INFORMATION) Date: 1--1-as-�4 City or Town of: 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) 65 L Owner or Tenant ij or.�a1c, G�tit Telephone No. Owner's Address Same as above Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building Dwelling 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: Re��c�C-e d.-,zjwAB\1e.R %ti rC ti Completion of the followingtable may be waived by the Inspector Of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above o.o Emergency Lighting 4 No.of Luminaires Swimming Pool d, ❑ d. ❑ Batte Units No.of Receptacle Outlets No.of OR Burners FIRE ALARMS No.of Zones No.of Gas Burners No.of Detection and No.of Switches Initiating Devices _®\' No.of Air Cond. Total No.of Alerting Devices (�! No.of Ranges Tons eat Pum Number Tons KW........... No.of Self-Contained P ..... . .. . .. No.of Waste Disposers Totals; """"""""'""'"""'"""' Detection/AlertingDevices unicipal No.of Dishwashers 1 1 Space/Area Heating KW Local❑ Connection ❑ Other Heating Appliances 1 ' Security Systems: e No.of Dryers g pp No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters: KW Signs Ballasts No.of Devices or Equivalent Telecommunications-Wiring: No.Hydromassage Bathtubs No.of Motors Total HP INo.of Devices or E uivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: $650.00 (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,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Northeast Electrical Services INC. LIC.NO.:20782A Licensee. Daniel B. Kobus Signare C.NO.: tu (If applicable,enter"exempt"in the license number line.) Bus.Tel.No:508-966-7467 Address: 40 N.Main Street, P.O Box 361, Bellingham.MA 02019 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 Telephone No. PERMIT FEE. $ Signature The Commonwealth of Massachusetts �i Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual):Northeast Electrical Services Address:40 N. Main Street, P.O Box 361 J City/State/Zip:Bellingham, MA 02019 Phone#:508=966-7467 Are you an employer.?Check the appropriate box: Type of project(required): 1.7 I am a employer with 24 4. ❑ 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. Q Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp,insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]f 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:Automatic Data Processing Insurance Agency,Inc. Policy#or Self-ins.Lic.#:NOW428117 Expiration Date:7/29/14 Job Site Address: City/State/Zip:t,�om�� vwrz�v►r�o1$4�5- 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 MOL 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 EELti&under the pa ns a d enalties o er ury that the information provided above is true and correct Si ature:E Date y"a'� - `{ Phone#:5 - 66-7467 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#: Division of Professional Licensure: License Search Page I of I The Official Website of the Office of Consumer Affairs and Business Regulation(C)CABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home> Division of Professional Licensure> ONLINE SERVICES .......... ................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure........ Online Address Change Contact the Agency more.. LICENSEE Name:DANIEL B. KOBUS REFERENCES& Business: NORTHEAST ELECTRICAL SERVICES INC i RELATED INFO BELLINGHAM, MA Disclaimer Regarding Website License Searches **This Licensee has addLtioR_41 Licenses,click here to view them.** Glossary of License Status Codes Licensing Board: ELECTRICIANS Mme... License Type: MASTER ELECTRICIAN TYPE CLASS:A License Number: 20782 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 4/2/2008 Exam Date: 4/2/2008 School: WAIVER This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday,April 28,2014 at 12:56:00 PM. Oc 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://Iicense.reg.state.ma.us/public/pubLicenseQ.asp?board—Code=EL&type_class=—A&li... 4/28/2014