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HomeMy WebLinkAboutWiring Permit - Permits #12396 - 11 COCHICHEWICK DRIVE 5/29/2014 Date ..'� � ................... t&ORTij ,p°��,`•" '•,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ncHua� This certifies that '... ....... ............ u i has permission to perform"� " ' ` �� ....... ...... .:. ...... ... ............... r wiring in the building of.............. ' .................................... .................................. C at ... .: ...:.... `; North Andover,Mass. Fee........ '...............Lic.No. ..............'.... ...E..... °..C...� EL lc INSPECTOR Check# "° common weafth Of Massachusetts cial Use Oni, Deparbnent of R,-,.Services i Permit BOARD OF FIRE PREVENTION REGULATIONS cupancy and Fee Checked ev-- 111991 Cleave bLmk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed ffi a=1d111e With rime Massachusetts El C,.,M -00 K OR TYP7, ALL WORAYA YTOA9 Date: rPLEASE PRINT 2;EV ectrical Code(WC).527 . 12 Cit)r or Town of: I "\, ) / 12 I I � , 4,1� 111� (al To the oj wjrff,,.- By this applioatioa the mdersi�e�v� of his or her intention to,perform the electrical work described below. Location(Street&Number) )i C 14, 0 V, Map: Owner or Tenant Telephone No. Owner's Address is this permit in c0ftiftucthM wilt a building permit? Yes No FL�/ Building Permit Purpose of Building— Utility Authorization Etsting Service Amps volts Overhead F71 Undgrd M No.of Meters New Serv?�e Amps VOHS Overhead ❑ Undgrd 7 No.of Njeter. Number of Feeders and Ampacity Location and Nature of Proposed Xlectrical Work: (I S 4 Y510 1,L t, , I - 11 p n of the g table ma No.of Recm essed Fbiures NaN Of Cell.-Svsp�(Paddle)Tans No:-of followin y be waived by the Inspector of Wi?-6 ITransformers M No.of Lighting Outlets Na of Hot Tabs cseneratars KV A No.of L4ghting Fbmm Swimming pool Emus No.ofRaceptude outlets No.of Oil Garners FRIE 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 Alin Devices Tons I Alerting No.of Waste Disposers Pump I Number I Tons !KW No.of_ Totals- WAIertha�g Devices No.of DMwashers Space/Area Heating KW U1.1 Other Connection No.of Dryers Heating Appliances KW Security., !11 In s:ices or aimAent No.of Water KW NO.of No,of Data Wiring: Heaters Signs Ballasts I No.of Devices or Eavivalent No.Rydromassage Bathtubs No.of Motors Total HP Te4eco I Wrung: *13*7 1 No.of Devi or,Xg - t Attach additional derail if desired,--required by the Inspector of 17 INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provide,proof of liability insurance including"completed operatjon�'coverage or its substantial equivalent. The undersigned certifies that coverage is in force,and has exhibited proof of same to the permit issuing office. r� CHECK ONE: INSURANCE i�7 BOND El OTHER 0 (Specify-) —UU4 (Expirato A 31 Date) Estimawd Valua of Electrical Work* (When required by municipal policy.) 7 Space/Area 'Heatin g -,RWN Work to Stark Inspections to be requested in accordance with MEC Rule 10,and upon coripletion. cerd.fy,under the pains and penalties of perjury,that the information on this application is true and conVlete. FEW E ea,4,-Ic- Tfir, , I LIC.NO.-.-,Lq �V) Li '4)JOJI?/7 1*) Ll no Signature 1C. NO.: -1 (7f applicable,enter in the license nwnur line. Bus-Tel.No.: 9F�-R Alt-Tel.No.: Address: MA -5 fi= -�a, OWNER'S INSURANCE WAIVER* I am aware that Licensee does not have the liabilk-Y insurance coverage normally required by I By my siartatare below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's owner/Agent [PERMIT FEE: S Signature Telephone No- C A 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 Applicant Information Please Print Le�><bly Name (Business/Organization/Individual): )n jc� f ffI Fx% Address: City/State/Zip: U* Phone #: w',). Are you an employer? Check the a propriate box: 4. [� I am a general contractor and I Type of project(required): 1.©'I am a employer with�__ 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 g• ❑ Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp. insurance.' 9• ❑ Building addition required.] 5. ❑ We are a corporation and its 10.ZElectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 152 12.❑ Roof repairs c.insurance required.] '' , §1(4), and we have no employees. [No workers' 13•❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iHomeowners 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. X 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. Lic, Expiration Date: _u7—/)/(i Job Site Address:11-&l C W1 C kA-1 g)IC V City/State/Zip:�bFA!x I;/ AA 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 tine 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 do hereby certi,fy under the pains and penalties of perjury that the information provided above is true and correct. Sip-nature: Date: O Phon_ e#: l� C � y f-� 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#: