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Home My WebLink AboutWiring Permit - Permits #12060 - 130 BAY STATE ROAD 12/18/2013 Date � s � �µoRr"�ti TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �88ACHUg� 1 f� d ..t . ......... This certifies that � a t has permission to perform i.. ............ wiring in the building of .. o Andover,Mass at ... �.:;N z ....... P rth al 3 � Lic.Nor F ... .'... .. EI F�CCRICP L INSPECTOR , Fee ...�:.......: .. � 11 F P Check# ti 2' pp l N Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME 12.00 (PLEA SE PNNT IN INK OR TYPEA LL.TNFORM TION) Date: 'P'?,e`41 lev- /F., --)o I y City or Town of: NORTH ANDOVER To the nspector of Wires: By this application the-undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)_Ida Aeli sjq,-k Owner or Tenant ffevigu 1)v lee iv Telephone No. Owner's Address S,?0,Lr Is this permit in conjunction with a building I permit? Yes No ❑ (Check Appropriate Box) Purpose of Building W 5 Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd[:] No.of Meters New Service Amps Volts Overhead❑ UndgrdF] No.of Meters Number of Feeders and Ampacity I Location and Nature of Proposed Electrical Work: &51)Aeft-1 ke"Ivq 40' x) Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cefl.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool love In- 17o—.-o-ff mergency Lig tmg irl grrid. Batter v Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo, of Zones No.of Switches No.of Gas Burners No Detection nud Initiating Devices No.of Ranges No.of Air Con d. Tons Tot No.of Alerting Devices al Heat Pump T No.of Self-Contained No.of Waste Disposers Totals: .Number Tons KW Detection/Alerting Devices F❑I Municipal F1 Other No.of Dishwashers Space/Area Heating KW Local Connection No. of Dryers Heating Appliances 11?1W SecuritySystems:* No of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts - No.of Devices oi-Equivalent No.Hydromassage Bathtubs No.of Motors Total UP Telecommunications Wiring: No.of Devices or Ea uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 covcrW is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND n OTHER [I (Specify:) I certify, under fi . andp na1t1esofpe1y'U!y, that he information on thisTVIcallon is true and complete. the palps /T N LI F A 111,7"e C.NO.:C;�>P7 Licensee:1�pl.�r s j rt1✓1% Signatur t LIC.NO.: ble,pr "ex t'inthe license number Bus.' -2 (If applica o I Tel No - , , _ 0 - ? 01 0 /T V line o vet- tvt gs" 'No -5—r—t-1111y Address: Alt.Tel. *Per M.G.L 6. 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)[I owner._ 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT_ FE" FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is td promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule R—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: t Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspecto s Signature: Date: ROUGH SPECTION. Pass Failed Re-Inspection Required($.) ❑ Inspectors Comm Inspectors Sig ture: Date: FINAL INSPECTI Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le gib Name(Business/Organization/Individual)(—� "5 leo � Address: P l9 Se /J City/State/Zip: P(- 14110 t'cif'` M of Phone 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 2. I 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.❑ 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. 'Homeowners who submit this affidavit indicating they aie 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.Lic.#: Expiration Date: /� y, Job Site Address: / 30 �� Y tt'' /C�'�'! City/State/Zip:W 1%00ver MA 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 o. 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' surance coverage verification. I do hereb ert and z ains d n ties of perjury that the information provided above is true and correct. % atu Date: Phone# 7Fl �r r 7 �9 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: ti COMMONWEALTH OF MASSgGHUSET < BOARD of Ede- CIANS ISSUES THE f:OLLOWING LICENSE AS A REGl5TERED MASTER ELECTRICIAN r Z -t CHRISTOPHER W VINiNG w; IJ i P O.-Box: 115 NORTH A'NDOVER MA 01845 0115 111 b 79.. 2098 0713 0 D f �R el- ��