HomeMy WebLinkAboutWiring Permit - Permits #11432 - 57 COBBLESTONE CIRCLE 2/28/2013 Date
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.. PERMIT FOR WIRING
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This certifies that t
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has permission to perform �
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wiring in the building of....................:: .... 9....:......................................................................
jat ... .. :. r.. ........` ...North Andover,Mass.
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Fee. ........:......Lic Noy 'tj! y. '. r,.r.:........
u INSPECTOR
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(flmmonwea&of Vamac4u-letb Official Use Only
Permit No.
Apartment ol3ire Semicei
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (l....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, PRINTIN INK OR TYPE ALL�NFtO�RMALION) DCorToo ')/ To the Inspector of Wires,/, e-), -
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 2 ( / � f, f' ',N,
,-5 --62 L�k I A /V - "Z i,
Owner or Tenant z&2 J1 61C 51 121- Telephone No.
Owner's Address a2z—!�2
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose ofBuilding Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd El No.of Meters
New Service Amps Volts Overhead❑ UndgrdEj No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Conipletion of thefiolloii,ing table inay be ivaived by the Inspector of 117ires.
No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers I(VA
No. of Luminaire Outlets No.of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above Ei In- 0 0'ol Emergency Lighting
gnid. grild. Battery 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
No. of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No. of Waste Disposers Heat Pump ..........I(A. No.of Self-Contained
Totals: Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local El Mmu"'P!d El Other
Connection
No. of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
Na. of Water No.of No.of Data Wiring:
Heaters KW I Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wi No.of Devices or Egtil"vNent
OTHER:
Attach additional detail if desired,or as required by the Inspector of J17ires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: • 2�', "l."I.3 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 [fl-` BOND 0 OTHER [I (Specify:)
I certify,un(let,the pains andpen alties 0 etjmy,thattheinforination on this application is true L
FIRM NAME: /-5 LIC.NO.;
Signature LIC.NO.:
(Ifapl)licable,enter "exempt"in the license number line.) �43us.Tel.No ?�z
Address: '
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0 q / ') av< �o kv t', (;!,40 ,Al A(14/9, t Alt.Tel.No.:
*Per M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAIVER: I arnaware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. 1 am the(check one F]owner El owner's agent.
Owner/Agent 'r,�--
Signatin e Telephone No. FEWMIT FEE: $
16156'
'� The Coy. m nigeaZth o`'Hassachusetts t rlrgl: n m=
J;�M� - De�a>^urgent of XndusirialAceld'ents
�.T_ �� Office ofImesid a'dons
' . 600 Was.Wngton Street
w Boston,MA 02111
Workers' Compensation Insurance Affidavit: ors
Name(Business/oiganizatioji&dividual).
.Address: ; �csmt„ „�
Ci /Mate/Zi ,
Are you an,employer?Check the appropriato box: Type of project(required):
1.0 S am a employer with 4. E] x am a genexal contractor and 1 6. ❑New construction
employees(full and/or part;time).' have bared the sub-contractors
2.JUfam a sole proprietor or partner-
listed on the attached shoot. V. C(Remodeling
ship and have no employees These sub-contractors havo g. Demolition
working for me an any capacity, employees and have workers 9 Q Building addition
[No workers'comp.insurance comp.insurance:
xequited,j S. C( We are a corporation and its 10.P-Electrical repairs or additions
3.❑ x am a homeowAor doing all work ofdcexs have exercised their 11,C(plumbing xepairs or additions
myself, o workers' right of exemption por NXGI,
y comp. o,152 §1(4) and we have no 12.�]Roof repairs
ansuxancexequared.1 i employees.[No workers' 13,Q.Other
comp,insurance xequircd,]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensatioli policy information,
Romeowners who submit this affidavitindioatiug they are doing all work and then hire outside contractors must submit knew affidavit nudica*such.
'TContractom that check This box must attach6d an additional sheet showing the name of the sub-confracfors and sfate whether or not those entities have
employees. If the sub-oonfraefors have ea ployees,they mustprovide their worker's'comp.policy number.
.Z'a�,�an erxtployer tZ2at�Spravir�irzg.7vos7cers'comper2satior�ir2sur'ar2ce fora arty ernproyees .13etow rs t/i�p�Zzcjs ar2d.'jo7�sits
znfbrr,'gatt"on.
Insurance CoxopanyN•ame:
Policy#or Self ins.I:ic,#f: Expiration Date:
fob Site Address: ___� City/State/tip:.
r
.Afftach a copy of the Workers'compensation poNcy declaration page(showing the policy number and expiration date),
failure to secure coverage agxequaredundea'Section25A ofMOI.c. 152 can lead to the imposition ofcrimivalpenalties of a
f e up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form.of STOP WORD ORDER and a one
of tip to$250,00 a day against the violator. Do advised that a copy of this statement may be forwarded to.the Office of
Investigations of the DIA.for insurance coverage verification,
Xd,ohe,-ebyeerdjytsitde)-thepainsaiid enarties ofpeYjury that the infomnation provided above is trace arse,correct
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Si ature: a bate .. ... �
Phone#: z., .. 3 ZZ
LLOth
e only. Do not write in this area,to he completed by city or town offtciaZ
m: PermitUcense
thority(circle one):
ffe< 2.Eu ldingDepartment 3.City/Town.Clerk 4.Eleetrzcalfnspector 5.Plumbing Inspector
rson: Phone#: