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Home My WebLink AboutInsurance Letter - Permits #12764 - 25 CRANBERRY LANE 9/23/2014 Date...4.s..........,...... ............... of NopT qti TOWN OF NORTH ANDOVER o PERMIT FOR WIRING ss�CHUSE r � G This certifies that ...,,.. .[... .. � 4 ' has permission to perform e j c t..... ............................................ ....... ................ 4 � wiringin the building of........ ,..�..... ...... .. ....................................................................... at ,.,,..... h ... North Andover Mass. - Fee........ F� . Lic. No. ,. �t u n .............................................................. ...... ELECTRICAL INSPECTOR Check# '0 r t - Commonwealth ®f Massachusetts official Use Only Department of Fire Services Permit No. 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(AEC) 527 CMRZ2.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: Z City or Town of: NORTH ANDOVER To the Inspectd of Miles: By this application the undersigned gives notice Eifs or her intention to perfo the electrical work described below. Location(Street&Number) t2 Owner or Tenant PAU I s Telephone No. Owner's Address Is this permit in conjunction with a building perm, ? Y z!' Yes No ❑ (Check Appropriate Box) Purpose of Building ` 6 h ��' l r y 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: p p 2�IyrC'U1 Completion of thefollowing 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 ❑ In- ❑ o.o mergency Lighting rnd, rnd. Batter Units No.of Receptacle Outlets 2, No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: """'"""" ' '"" ' """ Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW SecN.o DeviSysteces s 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 Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 07res. Estimated Value of ectrical Work: — (When required by municipal policy.) Work to Start: 2 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE VERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force,and has exhibited proof of s mk1le"ZoEs mit issuing office. CHECK ONE:'INSURANCE BOND ❑ OTHER ❑ (Specify:)I cent fy,under thepain and penalties q f perjury,that the information on at ap true and complete. FIRM NAME: , e � LTC.NO.ZY r Licensee: Signature LTC.NO.: (Ifapplicable, enter "exempt"in the license number line) Bus.Tel.No.: _ Address: 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)❑owner ❑owner's agent. Owner/Agent .PERMIT FEE. $ Signature Telephone No. ❑ 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 shail.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 ofthe Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to 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 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass ? Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: r SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.} ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.}❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comm ts: Inspectors Signature: Date: FINAL INSPECTION: Pass a Failed Re-Inspection Required($.) ❑ � Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com _ c -- " ` 5-5 SALEM ST MORTH ANDOVER MmA 0T$45 3 i GCS Fold,Then Detach Along All Perforations ,;... C;6MIVl3 it17 �" ( O`F'M `ACF'i ? a . . . ® Z F.. 1k 1.F Sti}Fr� T ' EN Ft .tBA a AJ.. .�y7 r t INN i 845 31 a9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations '600 Washington Street Boston,MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `'� Please Print Legibly Name(Business/Organization/Individual)`: �, �h Ole(/rn i(i (z L Address: 0 /fit 1G° L?A4 l )t City/State/Zip: d4k i W Phone#:_ 5) 693 608 Are y an employer?Cheel t appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑N construction f employees(full and/or part-time).* have hired the sub-contractors 2.01 am a sole proprietor or partner- listed on the attached sheet.1 7 emodeling 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' comp.insurance required.] 13.❑Other *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. 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: d / Attach a copy of the workers' compensation-policy eclaration 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. X do hereby cent u e t1 ain an pet alties o erjury tliat the information provirlerd ab a is ue and correct. - Signature: Date: Phone#: 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#: