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Home My WebLink AboutWiring Permit - Permits #12940-1 - 16 COMMONWEALTH AVENUE 12/9/2015 TOWN OF NORTH "4 L. t __....... ..ww... k PERMIT C WIRING 31 r� Am 0/1 wo ll �� r a It°�,;permission din gqe�:fia�a�� ;;� e �✓ur Ka� gut t9Mw�k��rM9a�i�u ��C " . �. at . . ...... a �' " . Noilh Andover, Mass.Fee, + / Check / Yff Commonwealth of Massachusetts Official Usc.Only 0 Department of Fire Services Pernift No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07],_. A (teave blank) PPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work tobopei-foi-ti3edif.iaccotdaiice-ally tltel\4assCtolitisot[sElectrical Code 5(MEP), 27 1\4R12.00 (I'LLIASW PRIM'XINK ORTYPE ALJ,11VTORMATIOAr) Date: AQ/ , 7;/�,— -- City or Town of: NCB RTHANDOWR .............- To the in—sImetor qf'Wires: j�- 'd-j,7iW By this application tile undersig s notice of his or her intentionto perlbrii'l tie electrical work described below. Location(Street& Number)- - ----- ..........Owner or'. J -1 0'T,(ee l ephone No. Owner's Address .................. Is this permit in conjunction.with a building perfidt? Yes No -late Dox) (Check Appropi Purpose of Building. .......Utility Authorization No.----- Existing Service Anips Volts OverlicadE.] Undgrd[J No.of Meters N.qw Service Am D ps Volts Overhead Undgrd No.of Meters Nui,riber of Feeders and Anipacity, I ocatioii and Nature of Proposed Electrical Work- ............ tal)fe maybe waived b the kv ector o Wires. NO,—of No.of Recessed Luminaires No,of CeIL-Susp.(J."addle)Fans Trans Total Transformers KVA .............. No.of Lurninaire Outlets No,of Hot Tubs Generators KVA A ove In- nd No.of Luminaires Swimming:fool b .... ............ El 0.o !,M Uni tsergeney�Ig tln�g d. ar . BatgfUer ............ No.of Receptacle Outlets No.of Oil Rurners FRW ALARMS ............................... NO.—(;i;ones No,of Detectionand Na.of Switches No�of Qis.turners Initiating Devices ....................— Total No.of Ranges No.of Aft-Cond. Tons No.of Alerting Devices KW No.of Self Contained No.of Waste Disposers Tota Is Detecflon/AlertlngjDevlqes ........... ei �I`/ I _ ,�-.Deal n Municipal No.of Dishwashers Space/Area Reating KW Other Connection No.of Dryers Heating Appliances Security ysl:e&� �KW No.of Devices or Equivalent E No.of Water N (f Heaters KW Dati Wiring: Sims Balhists No.of Devices or Equivalent No.Hydroynassagellatlitut W(03.of Motors 1,0talIff, 1'elecounnunic tions Wiring: a, ..... -------------- .................. No.of DevleRcs or 1, OTHER: .......... wd-p—sired—or as-r—eqelre by the Inspector of Wires. Work to Estimated Value of Y�ectri al)york: ("llien required by rnunicipal policy.) S1 hispectiaris to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE 7(�,"i5V—r4,li-A6'F—,- thiless waived by the,owner no permit fbr the performance of electrical work may issue unless the licensee provides proof of liability insurance including"conipleted operation7'coverage or its substantial equivalent, The undersigned certifies that such coverage is in fbrce,and has exbibitedproofof same to the permit issuing office. CHECK ONE: INSURANCI] El DOND E] 0`FJ--JFR .1 F" I certify ,under the Ains andpen.a 90fP 111111S lication is true and cony)lete YPT ;�109 1�2 C't C LIC",NO. FffM NAW 9f � 1( 1 - -------------- License d 1�5 T Signatur 11C.NO.: 2 ffa,r,plicable enler"exetnpi I Bus.s.Tel.No.- : 4.1 4�lo )Alt.Tel.No.: -cs Depw tuient of Public,Safety"S"License: Lic.No. secrk�r equh OWNE R'S INSURANCE WAI urifyVER:wo.1 am - aware that the Licensee does not have the liability insurance coverage normally required,by law. 13y niy signature below,I bureby waive tlos requirement. I am the(check one D owner D owner's agent. Owner/Agent &5 k Signature" ,...................----...—,Telephone No,_,,_.__. ................ di I n d `lire CommonitieclilfIr rqf Massachuselft r Department of id u trid A i."idesat, r ,°w : X C".driller e.ys Street,Srcfte.100 Rostotr,, 141,E 02.1.14..2017 / mvly rtacts°sagov1din Workers'Compensation Insurance.Affidavit:Ilaralder°s/Corrtraicrtor;sfJ+;fe:ctriciaiis/illumbers. TO BE FILED WITH THE 1'E RMI L"`1TING A tl"111C:RITY. Applicant Information on _ � Please Print Legibly Nate F E3 ,� � Ac�dreSd: e usnressl C)r urrtz°afro :ntrvrrua. Ci /Sttlte/%i a / � � �'I"tort �3 P ,._.__._.._.._......____....._ .....___ _....... ___....._........_..._.___._._ __..... _�-- ----..__-- l Are you our ernployer'l Creek the appropriatta box: Type of project(required): : t. 1 alit a employs r with (fall and/or prrt-tnge.* 7. New construction v rrn a so e solsietor or partnership and have no employees vvorkrng for mo its 8. Remodeling 3. I r am homeowner w flo r r'corrary in a .aro r oquircd.l ,ar 9t �7 9. 8�:..11)clnolitioll L.I er doing n1l work myself f No workers cxranp.insoranco reguia cc!�t to�—�Building addition � 4.[]I am a homeowner grant will be;haring,contractors to conduct till work on nay property. l wiU ensuro th at all contractors either leave workes'canal>ensation irusuaancc or are;sole 11—[]Electrical repairs or additions Proprietors with 110 e traployee^s. 1.2. Plumbing repairs or additions 5. 1 am a general contractor nand T have lrined the su b-o nti actors listed ore the attached,Meet, � 1,3.[ loaf repairs 6.Q We are a corporation amd its officers have exercised their tight of"'cxernpdor 'these sub-contractors have employees and have workers'ccanp.in nr Karoo. t per k'I(s'1'.o G. 152,§1(4),and we have no employees.[No workefs cornp,nasuranr a required.] *Arryapplicantthat checks hoxtllr astnlsof"all outtlrc,cutler¢rlrclnw;howurltheirwos9ccr carnlrerrartiorr]ralacyinirannariian. J t Homeowners who suhanit thus affidavit indicating they aru doing all work and then litre ouutside,contractors roust sr,ibnrit anew affidavit indicating snap. o, tC7ontractors that check this box rarest attached an additConal sires t showuag tlrc name ul tSae,sail c«ntr u tars arncl state Vvhcther or ptrt those on,tiC es]rave employees. If the sub-contractors have employees,they mtast provide their workers'comp policy number. I girt cm errtplayer tltaP,is rrar€rirlirz r wearlcerc'crcrnairensaticrn zit stir rzrtre./art pry ever Try Belo ty is the policy and job site information. Insurance Company Name:_ Policy#orSetf ins,Liu tP Expiration Tate: j Job Site Address. _.._._ _. C rty/`t ate/yip:._ r Nttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). f� J' Failure to secure coverage as required under N1C:1L c% 152,§25A is a,rr trnk4l violation punishable by a:fine up to$1,500.00 and/or one-year irnprisonrnent,as well as civil penalties in the faint of i 5`1"OP WE).fCaS ORDER and a fine of up to$250.00 a day against ille violator.A copy of this statement may be:forwarded to the Office of lnvcstig<ations o:f"the DIA for insurance coverage verification. 1 cln hereby ccrti• under e pains anti et ltles rr et:air that the.to tab°nation provided above is,trite ncl correct Phone##� 2 air Official use only. Do not write in this area,to be ccnrtpleterd by city or town gfjic^ial i l City or 'own: pernrftll.,icense fi i Issuing Authority(circle one,) l 1.Iioarcl of Health 2.budding Department: 3.t.ityrflown Clerk 4,Electrical Inspector r.Plumbinglnspector 6.Other_ Contact Person:--- _......__ .__._.. .. 1'hru;ne fl:._..._.._____._.__.__..__._.__._..__ /o ffff�f �f /,//,,;,..,.. .•:>-:rh�!.../.:�!.>�!..;;,,,1/.,,,r !,,,,,,, ,///rff�„//„r!/f1//,r,��,Irn,/,�//;,//fig,//%%/%, 1%//„%/ , �r//�i/ii,:.t,/l�iiiii/!iii/%%��%/i%�//�%,//////,iii%////„//�i////nr,ra I G r r r �J / ��/; y /�1111Y 1 1 fip / i 1 i aiacii/w iUaim�iiooiomn��/ri�i�.r//ir,✓mavr.///„/l///r,,,,,.,�1/a,/iia,,��/�r�//„r,a/..//,,,.�,,,/�1%,r/„�,i/lllrrrai/,,//,,,,,1,,,,,i,�.L///i,,,,