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Home My WebLink AboutWiring Permit - Permits #13219-1 - 10 CLARENDON STREET 3/24/2016 Y ; Date .:� ...... � ..... O�NOti7N 1 TOWN OF NORTH ANDOVER *O PERMIT FOR WIRING Cp g$ACHUS� This certifies that � c . "'J .). has permission to perform " i wiring in the building of L 1/ F�:: :......... at .............................. ..................::................ .... ............,North Andover,Mass. `8 Fees .............Lie. No ��.E . ELECTRICAL INSPECTOR Check# ` Commonwealth of Massachusetts Of d 1 Use Only t Permit No. Department of Fire Services -- ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �/ City or Town of: , () 42; To the 114ector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ( �- l Owner or Tenant L I Gko L ,, Telephone No. ) t Owner's Address /% ,.. i" s, l . I. � , Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. : / C/021 Existing Service Ido Amps ICJ/ ,,Volts Overhead ❑ Undgrd❑ No.of Meters ' New Service Amps 'c / Volts Overhead Undgrd ❑ No.of Meters 2— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: K ( ]..YW) :5 Corn letion o 'the ollowin table may be waived by the Inspector of 91ires. No. of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total (�,) Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA Above In- o.o mergencyLighting No,of Lighting Fixtures Swimming Pool rnd. ❑ rnd. El Batte 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 Initiating Devices Total No.of Ranges Na.of Air Cond. Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Connection Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent o.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts I No.of Devices or Equivalent °w No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications o. Device or E Wiring: t Equivalent OTHER: Attach additional detail if desired,or•as required by the Inspector of Ores. 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:) (Expiration Date) 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. certify, yNA under ME: p �te a u❑ttperTaltr es of perjury,that the information on this application is true and complete. FIRM ,. u � LIC.NO. . ri Licensee: , °" _ Signature LIC.NO +5515116 (/fapplicab/ , nt "exem t" 7r 1 lic txse ntrnaberline.� Bus.Tel.No..1 d °" (, �"" Address: " 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: $ Signature Telephone No.,� b M --►L 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 Legibly Name (Business/Organization/Individual): Address: Y' 04, r City/State/Zip: //L7vt�2 / '� Phone #: %hrc /' Are you an employer?Check the appropriate box: Type of project(required): 1.u l am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *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 their workers'comp.policy information. I ant an employer that is providing workers'compensation:insurance for my employees. Below is the policy and job site information. Insurance Company Name: �c 1�me2n&oo Policy#or Self-ins.Lic.#: ,el& Expiration Date: f 21-13�041 � Job Site Address: City/State/Zip:,d, fA o.)t)t,,(— 419 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. --- /�-- ....,.. .f1 J �' .f provided above is true and correct. o hereby certify under a paints nd penalties o ner'u that the information rovir r' Signature: Date: Phone#: 0�S)l 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#: Transaction Type: Request Certificate Of Insurance Agency Information Producer Code: Agency Name: Submitted by Name: bryan Logue Email Address: bryan@bplogue.com Agency Phone Numbers: Contact Preference: Email Policy Information Policy Number: 46WECAQ8737 Name of Insured:BPLOGUE&CO DBA BPLOGUE&CO Effective Date: 03/18/2016 Certificate Details CertificateHolderName: town of north andover Address: 120 main st, north andover, MA- 01845 CertificateHolderType: Evidence of Insurance Only Delivery Method: Email Send by Email: bryan@bplogue.com Additional Comments Comments: oo61f1m®NW94TM OF 6�IiASSAGM �f)? 1...:_... ;BOAFlb OF El E CTR I C LANS ISS.UESJHE FOLLOWING LICENSE jut AS A REG JOURNEYMAN;:.ELECTRICIAN 4 BRy,AN; P LOGUE. 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