HomeMy WebLinkAboutWiring Permit 8/28/2015 Date o11r............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
............
HU
This certifies that\,k
....Z................................................................................................
has permission to perform ...6.... ......... . ...... ...................
wiring in the building of
I...........................................................
aty...... hA:......................
. .
......... NN I And
over,Mass.
Fee. 5 Lic.Na;�--(
...............
..... ................. .... . ....
L E C T R I C A L''INSPECTOR'**''**'** '***'*'
Check# c�,0
FH
-� _ r
ii
r
r Common wealth of Massachusetts Official Use Only
t Department of Fire Se Permit No. Ip Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS
[Rev. l/07] eave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ),527 CMR 12.00
(PLEASE PRI T NI11rK OR TYPE ALL.INFORMATION) Date: — Z j - p/s
1 City or Town of. NORTH ANDOVER
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)
Owner or Tenant Telephone No. 571- 2
Owner's Address V V - 3
Is this permit in conjunction with a building permit? Yes ❑ No
(Check Appropriate Box)Purpose of Building Utility Authorization No. S,
- Existing Service Amps / _Volts Overhead❑ Undgrd❑ No.of Meters
New Service
,i Amps / Volts Overhead❑ Undgrd ❑ No.of Meters m
i Number of Feeders and Ampacity r
- i;0141 �Iia cxi c� C� ! F A c i o-.v.
Location and Nature of Proposed Electrical Work: _�� J i
Completion of the followin table maybe waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Total
No.of Ceil:Susp.(Paddle)Fans e,
Transformers KVA4 No.of Luminaire Outlets €
No.of Hot Tubs Generators KVA
\ `
No.of Luminaires Swimming Pool Above ❑ in ❑ o.o mergency ig t►ng
rnd. rnd. Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones \
No.of Switches No.of Gas Burners No.of Detection and \ ''
Initiatin Devices
No.of Ranges Total
g No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump 1 Number Tons KW No.of Self-Contained
Totals: ................. ....
Detection/Alertinir Devices
No.of Dishwashers Space/Area Heating KW Local Municipal
❑ Connection ❑ Other K
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of No.of Devices or Equivalent
KW
Heaters No.of Data Wiring:
Si ns Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: k
No.of Devices or E 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,tinder the pains and penalties o perjury,that the information on this application is true and complete.
FIRM NAME: �e ' CJ LIC.NO.: Zc66
Licensee: �(� �, cLLK�,��(y1 Signature
(If applicable,enter `exempt"in the license ntember line.) LTC.NO.:
Address: '�L/n,�� / (T. A� ;4&h L/^f ��� Bus.Tel.No.: C)
a*Per M.G.L c. 147,s.57 61,security work requires Department ofPublic Safety Li : Alt.l c.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
Signature Telephone No. PERMIT FEE.$ Cjrj—
❑ 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 1!
notification of completion of the work as required in M.G.L.c.143,§3L.
ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
Permits shall be limited as to the time of
or she has determined that the authorized work has not commenced or has not progressed during the preceding 1 e terminated upon the written
period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be termi
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chanter 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 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 Ins ection
Pas
Failed Re-Inspection Required
s
($.) ❑
Inspectors Comments:
Date:
Inspectors Signature:
SERVICE INSPECTION:
Failed Re-Inspection Required
Pass M ($.) ❑
Inspectors Comments:
Date:
Inspectors Signature:
PARTIAL ROUGH INSPECTION:
Failed Re-Inspection Required($.)❑
Pass 0
Inspectors Comments:
Date:
Inspectors Signature:
ROUGH INSPECTION:
Failed 0 Re-Inspection Required
Pass R ($.) ❑
Inspectors Comments:
Date:
Inspectors Signature:
FINAL INSPECTION:
Failed Re-Inspection Required
Pass R ($.)❑
Inspectors Comments:
Date:
Inspectors Signature:
DEB WEINHOLD ..TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ 1 Congress Street,Suite 100
Boston,MA.02114--2017
www.massgov/dia
VPo kers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plwnbers.
�
TO BE FILED WITH TICE PERM ING AUTHORITY.
A hcant Information _
Please Print Les=ibly
Name(Business/Organization/lndividual): �
S G_ l t�
Address:
tate/Zi �N!�t�ri` � 1�o Phone#: t��^t
City/S p: z.. . .
Are you an employer?Check the appropriate box: Type of project(required);
13 am a employer with _employees(full and/or part-time).* 7. ❑New'consttu'otion
2.0 lam a sole proprietor or partnership and have no employees Working forme in 8. Remo deft
any capacity.(No workers'comp.insurance required.] 9. ❑Demolition
3.❑I am a homeowner doing all work myself(No workers'comp.insurance required.]t 10[]Building addition
4.C]I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole
l l.❑Electrical repairs or additions
proprietors with no employees. 12,[]Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11[j Rb6f repairs
k These sub-contractors have employees and have workers'comp.insurance.t 14 Other
6.Q We are a corporatiori and its,officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
i
' *Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy information:
"y i Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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(hose 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
x information.
<t Insurance Company Name-
Expiration Date_
Policy#or Self-ins.Lie.#: _
Job Site Address: C City/State/Zip: Xl .4.iv
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
152,§25A is a criminal violation punishable by a fine up to$1,500.00
Failure to secure coverage as required under MGL c.
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
orwarded to the Office of Investigations of the DIA for insurance
day against the violator.A copy of this statement may be f
coverage verification.
hat the in r
f
t ormation provided above is true and correct.
I do hereby certi,fy under the pa'
Date: Z O p p "
Signature:
— j
Phone#
[Official use only. Do not write in this area,tobe completed by city or town official
ity or Town• Permit/License#
ssuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
l Phone#:
Contact Person:
d
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
ofthe foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the
receiver'or trustee 6f an individual,partnership,association or other legal entity,employing employees.•However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(1)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
nece§sary,supply sub--'contractor(s)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be.filled out each
year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 wwwmass.gov/dia
r COMMO HUSETTS
1:8SUES THE :F.OLLO ING LIC1_NE AS A
REfi1STERED MASTER ELECTRICIAN
Y
JOSEP.tl.G ELKHOURY iZ
3y ,
27 CHARLES ST IfW
IJ
NORTH IUD WER. 14A 01845=1661+ �
.20056 A 07/31/16 39271
i ,