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Home My WebLink AboutWire Permit 13201 y Date....... ................................... t rWR►'M �d;.�•'�.._;!tioo TOWN OF NORTH ANDOVER a PERMIT FOR WIRING 88'�CMU'� Thiscertifies that . ...............Ii,................................ ....................................................... � i. has permission to perform �.... ....r /.. wiring in the btfflding of. t..t�...... ...... ........................ �at ... . ....... .�C yvy�'vN ?r, !::.........:.�`........ .....:�, orth�AV: n dA�o"�v�er,M..a...s..s.. - Fee..............................Lic. No. .'7 ........................ ... L CTRICAL NSPECTOR Check# t : Commonwealth of Massachusetts Official Use only Permit No. 7?z o Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07 ( i' [ leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M C),527 CMR 12.00 I PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ��3, t City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentiop to perform the electrical work described below. Location(Street& umber) nZ e fc- e- 1. ,L Telephone No. 0 �11-� LI ' Owner or Tenan !� �\ : 1 r Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. ��tgo?. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service r7-w Amps °-ai /4.90 Volts Overhead❑ ItUndgrd tig. No.of Meters-- Number of Feeders and Ampacity'—T kt A `lam 2 r Loca 'on and Nature of Proppsed Electrical Work: l ,,L Q45�31 Completion o the ollowin table may be waived b the Ins ector of Wires. 19 O.o Ota No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA Generators KVA No.of Luminaire Outlets No.of Hot Tubs 5 A ove In- o.o Emergency ig mg F No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 1 o.of Detection an No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices eat ump um er ons o.of Self-Contained No.of Waste Disposers Totals: Detection/AlertingDeviceskD unic No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other '# Heating Appliances Key ecNo. ystems: d No.of Dryers g PP No.of Devices or Equivalent N p No.of No.o Data Wiring: ' { o.o Water I{�y Ballasts No.of Devices or E uivalent Heaters Signs elecommunications Wiring No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Eau ivaent h OTHER: \ '2[t / Attach additional detail if desired,or as required by the Inspector of Wires. f Estimated Value of Electrical Work: sir i 000 O (When required by municipal policy.) i Work to Start:-,;n-Ant I:;-- Inspections to be requested in accordance with 1NIEC 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 [j�' BOND ElOTHER ❑ (Specify:) I certify,under he pal and enalties of perjyry,that the information on this application is true and complete. 14 FIRM NAME: l l- � LIC.NO.: I�� • Licensee: �tl i►�-� Signatu LIC.NO.:4ZRQrl2- (Lfapplicable enter " mpt"in the lice a number/i ` rr Bus.Tel.NO. ,i Address: Ll �[rS �- eta (Z Alt.Tel.No. � 3 *Per M.G.L c. 147,s.5 - ,security work requires Department of Pu lic 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 PERMIT FEE: $ Z9 .o" Signature Telephone No. r Print Form E The Commonwealth of Massachusetts Department of Industrial Accidents 4 Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Lesibly F Gilbride Electric,Inc. Name(Business/Organization/Individual): ' Address:21 Progress Ave Suite 2 Chelmsford, MA 01824 978-256-5571 a City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): z LEI I am a employer with 8 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling ' 2.❑ I am a sole proprietor or partner- These sub-contractors have g. ❑ Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑ Building addition o workers' com insurance comp. insurance.* [N p• 10.❑ Electrical repairs or additions E required.] 5. ❑ We are a corporation and its , 3.El I am a homeowner doing all work officers have exercised their I I.❑ 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 13.❑Other employees. [No workers' - comp. insurance required.] "Any applicant that checks box 41 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 f 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:Federated Insurance Policy#or Self-ins.Lic.#: 9894980 Expiration Date:10-09-2015 Job Site Address: City/State/Zip: 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. I doh ins and venalties o er'u that the in ormation provided above is true and correct. Date: Si natu Phone 't Eisonly. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son• Phone#: i 's Division of Professional Licensure: License Search Page 1 of 1 Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure ONLINE SERVICES ................................ .................--....................-............................................... ------------------------- .................................... .......................... Check a License Check A Professional License Locate a Licensed Professional By the nivicinn of PrnfPccional I icPncurP Online Address Change Contact the Agency More D 7 Name: JOHN D. GILBRIDE REFERENCES& RELATED INFO Business: GILBRIDE ELECTRIC INC CHELMSFORD, MA Disclaimer Regarding Website License Searches Glossary of License Status Codes Licensing Board: El FCIRlr[ANrN More MASTER ELECTRICIAN License Type: TYPE CLASS: A License Number: 15886 Status: r[IPRFNT Expiration Date: 7/31/2016 Issue Date: 10/28/1996 Exam Date: 6/3/1989 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. ---------- Division of Professional Licensure: License Search Page 1 of 1 4 Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES .............._................... ............._................................................................ ......._.... .............. .._........ Check a License Check A Professional License Locate a Licensed f Professional Bythe niviainn of PrnfPscinnal I ir.Pnsura Online Address Change Contact the Agency More Name: JOHN D. GILBRIDE REFERENCES& RELATED INFO CHELMSFORD, MA Disclaimer Regarding Website License Searches **T1vsLicEoseehasadditinnni I icense, r1irk here to view them"' Glossary of License Status Codes Mo re Licensing Board: FI FCTRICIANS MASTER ELECTRICIAN License Type: TYPE CLASS: A License Number: 7015 Status: CIIPRFNT Expiration Date: 7/31/2016 Issue Date: Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. i 't z t a F: i Date Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license_ _ fto�- /Sol j / 417 /S � . d 3) Insurance Binder not on file or expired / 4) No Workers'Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20,Suite 2035, North Andover, MA 01845 s ;j E �� i it k