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Home My WebLink AboutWiring Permit - Permits #11849 - 15 COLUMBIA ROAD 9/12/2013 Date , TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING BACHUg This certifies that ......... ....................................................................... has perl7llSS10II t0 perform ......pi B wiring in the building of.....:... `.....: ' .....:......................................................... at ......... " ......... .. .:.`...`a ti . .G. 3s... orth Andover,Mass. ............................ F Fee.'- ee...... `.................Lic No. ....`:.. � � L-�.......................... ........ .. ....... ELE CAL INSP OR i Check# t` � Official Use Only Commonwealth of Massachusetts Permit No.Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),52 CMR 12.00 -1(PLEASE PRINT WINK OR TYPE ALLINFORMATION) Date: 12- City or Town of. NORTH AN-DOVER 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) 'll!")", 6'0 U j$1 I Owner or Tenant Z q el Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate)Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead D Undgrd[J No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity V Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA Above In- F-1 0,Of E(—m ergency Lighting No. of Luminaires Swimming pool grnd. ❑ 11nd. " Batter Units e'"'s T G us: Luminaires 0 0 Cc N s No. Hot Tubs Swimming Pool (Paddle) n- a F) N I,( N KW N, [Detection/Alerting Devices N. No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No. of Swittelies No.of Gas Burners 0. of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons 0.of Alerting Devices Tons 9M No HeatFum Totals. Number I Tons of Self-Contained ............ Otal ................... .......... No.of Waste Disposers s T Totals: .......... No.of Dishwashers Space/Area Heating KW Local F1 Municipal r] other Connection No.of—Dryers Heating Appliances Im Security Sysevic—ems:* No.of Des or Eauivalent Heaters KW No. of Data Wiring: Si ns No.of Water No.of Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent 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 FJ BOND 0 OTHER El (Specify:) eerl#y, tin dar th epains an dpenallies o perjury,that the information oil dais application is true and complete, a e%q L`� c , LTC.NO.: FIRM NAME: k Licensee: Signature LTC,NO.: (YaPplieable, titer "exempt' i the 11,Fnsenumber line.)7� Bus.Tel.No.: Address: 1`i, 4,N("q5 e",4 1 V`e-, ' '5 ",P)/'t Alt.Tel.No.: *Por M.G.L c. 147,s.57-61,security work - """�,partment of Public Safety"S"License: Lie.No. requires apartment 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)[I owner 0 owner's agent. Owner/Agent Signature Telephone No. PkRMITFEE. $ The Commonwealth of Massachusetts Department oflndushialAcclknts Office of Investigations 600 Washington Street Boston.,HA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor8/Ele,ctricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationgndividual): Address: City/State/Zip: (A kLs_/Vt 0/ (11 Phone V: Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with_ 4. F1 I am a general contractor and 1 6. E]Now construction /employees(full and/or part-timo).* have hired the sub-coirixactors 7. []Remodeling 2.0 1 am a sole proprietor or partner- listed on the attached sheet.� ship and'have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity workers'comp.insurance. 9. El Building addition [No workers'comp.insurance 5. El We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 11.El Plumbing repairs or additions 3.El I am a homeowner doing all work right of exemption per MOL myself. [No workers' comp. c. 152,§1(4),and we have no 12.Q Roofrepairs insurance required.) employees.[No workers' nll other 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 anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. .1am an enployer that is providing workers'compensation insuranceformy employees. Below isibepolicy andjoh site information. Insurance Company Name:. Policy#or Self-ins.Lic. Expiration Date: Job Site Address: lCity/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MOL o. 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 maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. fdo]ieriby certio under the pains andpenallies ofpeiJury that the information provided above is trite and correct. 2-11 Signature Date: Phone#: Official use only. Do not write in this area,to he completed by cl(p or town official City or Town: Permit/License U Issuing Authority(circle one): 1.Board of Health 2.Building Department I City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: " OIViN14NWEALTH OF � tVUgSSACH(jSETI'S BOA b of ELECTRICIANS ISSUES THE FOLLOWING LICENSE q5 A REG JOURNEYMAN ELECTRICIgN. # KEVIN `A CASHMAN 14 #ATHENS DR fw SAUGUSUU Ma 01906-311 33630 E 5 07/31/16 f ' 50560 �,