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HomeMy WebLinkAboutWiring Permit - Permits #13142-1 - 52 CLARENDON STREET 2/29/2016 Date.... � � ."........... �pSORT/� TOWN OF NORTH ANDOVER PERMIT FOR WIRING s �,a q A CHUg� This certifies that E has permission to perform ............ c E' .................................................. wiringin the buil m of g .............................................................................. at .......`: :...................... ....`��.�.........................:........................North Andover,Mass. `7 Fee.. ............ Lic:No. ..,..:. '........................................................I....................... .... rf. ELECTRICAL INSPECTOR Check# " l Use Only � Commonwealth of Massachusetts Officia( `, i Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS [Rev /OancyandFee Checked 4 71 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3— 1—l (o 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) �) C1 ti r N Owner or Tenant 'j«,,h, jV V 0 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) Purpose of Building `--c5L c1 e w4 t ri'k Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ll, �,4 (Z e&,✓r.)c)C/1 1�vi i.e I c.,L, cj k,Cl n� Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires 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- ❑ o.o mergency Lighting rnd. rnd. BatteryUnits 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 No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.of ............................................... Totals; Detection/Alerting Devices \ No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No. of Dryers Heating Appliances KW Security Dev ces or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No of Devices or Equivalent OTHER: Attaeh-ditional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (�—u a (When required by municipal policy.) Work to Start: .3 I =( (ra 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 9 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true anti complete. FIRM NAME: , j o t�� C �'Icy c LIC.NO.: L Licensee: -r.)"f1 Signature _ LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.:C� 7c Address: I r S-v ---�a-., layd 4 I-A) : a z Alt.Tel.No.: "Per M.G.L c. 147,s.57-61,security work requires Dep6AInent of Public Safety"S"License: Lie.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 E]owner's agent. Owner/Agent PERMIT FEE: $ Signature �_ Telephone No. The Commonwealth of Massachusetts Department oflndustrialAccidents tl 1 Congress Street, Suite 100 Boston,MA 02114 2017 :. ;�°` www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/i lectricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information �T Please Print Lel4ibl Name(Business/Organization/Individual): 1 P't� Address: l .tit cam,n-►d ►2 City/State/Zip v kj•Z c; Phone#: 9 -7� ._26 1 —3(" C',/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am.a employer with employees(full and/or part-time).* 7. ❑New construction 2.�I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp,insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13. Roof repairs • These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] `Any applicant that checks box 4l must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit'his 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-coritraciors have employees,they must provide their workers'comp.policy number. I am an employer that is providing-workers'compensation insurance for my employees.'Beloty is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: I Expiration Date: /qob Site Address: Al, 4d o v, S" C- I tire- .✓ 0 4 �" 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent' un er•tl`ypains andpenalties ofperjury that the information provided above is Prue and correct. Si nature: �01�, Date: Phone#: Of al use only. Do not write in this area,to be completed by city or town official.. City or Towm—7 L— 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#: By the Division of Professional Licensure , „..ire r,�,. /i,,, ..,.✓i//,//>'., rr,. // r/ ari �., � ./ / ,,, ///,/i� r /, Licensing Board: ELECTRICIANS License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: E License Number: 37258 Status: CURRENT Expiration Date:( 7/31/2016 Issue Date: 9/12/1994 Exam Date: 8/6/1994 / /cs