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Home My WebLink AboutWire permit 13061 Date... .�. ,.�� .............. NopTM TOWN OF NORTH ANDOVER '' _ ' PERMIT FOR WIRING -PI 188��S�q q Lt ..................................J:1.... .T �:......' ...�... . This certifies that ..:��...� has permission to perform wiring in the building of... ..?..°rk.. ..........t...5.:.!(,{.. ................................. at ...� .��.... \... rY� ^. '.�::...................N rth Andover,Mass. Feb.....5. .�'?...`.......Lic. No. �o..� ...I .... ........... ,. . ELE.. ..CAL SPECTOR Check# Commonwealth of Madjachaaetta Official Use Only c/ Permit No. i b(.P i WIN Apartment.1 ire Service MY BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M C),52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / 12(j J 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)25 Commerce way Owner or Tenant Amastan Holdings 9 E Telephone No. 486 5171 Owner's Address 270 middle turnpike storrs CT 06269 Is this permit in conjunction with a building permit? Yes ❑ No ® (Check App[opriate Box) Purpose of Building��q,uy,6,q LJQy nw- Utility Authorization No.1770286 Existing Service E Amps / ..Volts Overhead ❑ Undgrd❑ No.of Meters New Service 1600 Amps 277/480 Volts Overhead❑ Undgrd ® No.of Meters 1 Number of Feeders and Ampacity 4 sets 500 MCM, CPR-1600 AMP Location and Nature of Proposed Electrical Work: Install a new undergrownd 1600 AMP service eXt Completion of the ollowin table ma be waived by the Inspector of Wires. No.of Recessed Luminaires E 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- El o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets Y No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and j Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons. .. .KW _ No—.of Self-Contained Totals: Detection/Alertine Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El other Connection No.of Dryers Heating Appliances KWSecurity Systems: No.of Water No.of No.of No.of Devices or E uivalent Heaters KW Signs Ballasts Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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: / 11.6 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 ofperjury,that the information on this application is true and complete. FIRM NAME: CKB Electric LLC LIC.NO.: 14361 A Licensee: Ernest R.Haru Signature LIC.NO.: 14361A (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.; •(978)685-0301 Address: P.O.Box 2062 Salem NH 03079 Alt.Tel.No.: (978)809-2,00 *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 Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents • Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Please Print Legibly Name (Business/Organization/Individual): CKB Electric LLC Address: 00 (Q �alern, lvr-1 City/State/Zip: non-7n Phone #: 685-0301 Are you an employer?Check the appropriate box: Type of project(required): L U 1 am a employer with_6 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ 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 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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: Hartford Fire Insurance Company Policy#or Self-ins. Lic. #: 08WECCM9941 Expiration Date: 6/18/15 L5 l�Ommerce Ivortn Anaover, MA Job Site Address: WR%, City/State/Zip: fl I QA 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 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. 1 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. I Sip-nature: Date 1/13/2015 Phone#: And �rn(1 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#: 'h-06TIAL. i0f tt t,,T-,#*'l C 1 AN -0,"L LOW I N G -:S SUE S T E NSE � 3 � P C, B IMc $j 8 i $ E N E ST R RD 90 LOWELL, 3 03�,V ''1 4 079, �'.6 48 ' MST k t trt� t e' d E f