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Home My WebLink AboutWiring Permit - Permits #13316 - 149 COACHMANS LANE 5/19/2015 i e- FI Date... `...::...:....`�.'...:::..::........... p10RTly TOWN OF NORTH ANDOVER 0 9 PERMIT FOR WIRING gs4CHU r 1 Thiscertifies that ........... ....... ............................ .. ......... ......... .,... ..:......... d has permission to perform s ....................... ............................................................ d wiring in the building of............................ .... :. ....:.::;7; ................................................... at y ......,.' L d` . .. '.. ....,..:a.....,North Andover,Mass. ........................... y Fee... Lic. No. ....................................... :..::..r...... ELECTRICAL INSPECTOR Check# s Official Use Only cy� cry Permit No. Occupancy and Fee Checked low BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAL4 YTON) Date: mow.. -- /q - City or Town of., A10 10-P) Agavex 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) 14(( C.0AJ%MJ4iQ LA"e Owner or Tenant Aj°r 6 m.&I At Telephone No. Owner's Address X 1'yl#,-- Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of Building '11-d 5 1 r r Utility Authorization No. Existing Service_ Amps Volts Overhead El UndgrdE:l No.of Meters New Set-vice Amps 1 Volts Overhead Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 17Lp- pt, o 'i) Complefion of thefollowin table may be-waived by the IMpector of Wires. No.of Recessed Luminaires No.of Cell.-Susp,(Paddle)Fails No.of --- ------To-t-flT— Transformers I(VA No.of Luminalre Outlets No.of Hot Tubs Generators KVA Above NO.01 me en' , ghting No.of Luminaires Swimmingpool grild. gurud. Batter lL lilts No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Dotection and initiating Devices No.of Ranges No.of Air-Cond. Tons No.of Alerting Devices Hen P76 No.of Waste Disposers t I 318W�P . Ef'Em... I 1(W Totals: Detection/Alertina Devices No.of Dishwashers Space/Area Heating KW Local El """'c'pal 0 Other Connection No.of Dryers Heating Appliances KW 3cGurity stems. cu N�rq%t stems: �mcess'o r E c i u I v A I I e n t WO.ofWater 0.0 No.of Heaters KW Ballasts Data Wiring: Signs No.of Devices or E ulvalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunicati,ens iring No.of Devices, OTHER: Attach additional detail if desired,or as required by the.Inspector of Fires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start-, V, "' 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 co erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND n OTHER E] (Specify:) I cerltfy,under the pains andpenattles ofterimy,that the inforynallon oft this applicalloll is true and complete.,, FIRM NAME-,,.->iA'F( I di.` LIC.NO.: 12 Licensee:kialo'D .1: ANiVA - 0 Signature LIC.NO.: (If applicabl enter t " "in the license, es exeng ut wnber line.) > L Bus Tel.No.i' We J,A Add U Alt.Tel.No.:('41 *PerM r G.L.c. 147,s.57-61,security work requires Department of Public 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/Agent Q owner's agent, Signature Telephone No. PE IT FEE: $ �� t� e \� The Commonveafth of0avachuseas Department ofludystriatAcciden& Office OfInvestiga&M 600 WayhIngtol,street Bostoyz,,MA 02111 iPiPw.mws.gov1dia Workers' Coxapensation bsurante Affidavit:DWIders/Co)atractorisiBlectxidawlplum*bers PIA00A pr, Name(Rus9neW0rganJzWcn9h&k%aI): G-rAm4ILIt49 UWU4AA.. I Addresxi—/10 �r*Ckgcam 5-r UtY/State/Zip: K CTR 0 1 N K A Of 0 44 Phone M. Am you an employer?Check the appropriate box: Type ofproject(required: 1. 1 am a employer with (a 4. El I am a general contactor and 1 6. n Now construotion employees(W-aadlorpart-the).* have hired fhe sub-conixactors 2. lam a solepropdetor or partaox- listed on the attached shoot t 7. E]Remodeling ship and liava=employees These sub-conlractors have 8. []Damolitton working for me is any capacity. workma"comp.inmirance. 9. D Building addition [No workms'comp.fusumco S. D We am a omporation and its I.O.EIRIectdcalrepairs or additions required.] officers have exerolsed their 3.El I am a homeowner doing all work right of exemption per MOL 11.n Plumbing repairs or additions �VseE 190 workers'comp. o.152,§1(4),imd we have n� 12.E]Roofrepairs mout-aaeo required.]t employees.[To workers' ME]Other ramp,insurance required.] !Aaw a"Hoont&a&eob boxgimustaUo fUoDttILasea6onb&w shewhag&ajrwo&=,comp msaffonlygloy ftA=afi0IL Nowm)wnm who nbmftMs affidavItindfmffisthey are doing all work and 1hen hire cublde contractors must submit anew aWI&vk&&a&g saolL *CDuftubra that check this box mast attached an additional sheet showing thaname oftho sub-contractorsandtfiekworbal corny,polloy fiformadon. I wn an employer gat IsyroWftg worhm'conWemadon huumneeformy employees Below fs thepo7tay ancijob,site information. - ja Insutance company Name: HP41LT ;QVS Amick Ca roji0y#or Self-its.Lio. Rviration pate. Sob SiteAddresx, I qq C Ac.IYVA--) aty/stato/ztp: ZV�Ao o-,eA,- HA Attach copy of the workers'compensation,policy declaration page(showing the policy number and expiration date). Failure to secure coverage,as required under Section 25A ofMGL c.152 can leadto the finposition,of oximInalpenaVes ofa. fine up to$1,500.00 and/or one-year imprisonment,.as wed.as CIVII penaMes in the form of a STOP WORK ORM and a fine ofup to$250.00 a day againdthe vfo . Be advised that a copy of1his statementmay be forwm*d to the Office of �Ivestlptlons dtho DfA for Jnsuxan(�Jovexago veaffloatlm P Xelo hereby e e.,Pahn 7 a1daqr FUrY that the informfibnpropMedabove is&ue andcoyreo4 er pate: note-#R.- VS o4,lzl' BE0 Offletat use on&. Do not Wift in My M4 to lie completed by efig or town official ffl City or Town: Pern*]Mcense# r o"v- a 0* r T:)[ssuIugAiuttThiorA-y(,circle one): Board[B EurdaMealfit 2.BuRding 3)epartment 3.Cltyffoym Clerk 4.Ble etrical hV ector 5.PImbing Imp utor 1 6.Other C ContartI. optactPerson: