HomeMy WebLinkAboutWiring permit - Permits #13246 - 80 CHRISTIAN WAY 4/22/2015 � .
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Commonwealth of Massachusetts
permit No.
Department of Fire Services
0copancy and Fee(,he*ked
BOARD OF FIRE PREVENTION REGULATIONS fjtcv,1/071 aaaveat1jk
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perforined in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00
(PLE,4S.EPJ?TN.`1'1ArNJ(OP.TYPEALL NF01MIYON) Date- 'I,4,;z S
NORTH ANDOV11'It
'M City or Town of. To the Inspector qf'Wires:
By this application the undersigned gives notice ofliis
or .b or jut nt on to perform the electrical work described below.
Location(Street&Z 1111ber) n49111,57"I"14 1')�l
................... .....................r Owner or Tenant Telephone No.
Owner'skildress ...............---------
Is this Permit in conjunctionwitil a urldrn acrnritr Yes No (Check Appropriate Box)
ITtility Autborization No.
Purpose of Buildlnv_-�;'l
Ex isting Service Amps Volts Overhead[A Undgrd 0 Na.of Meters
New Service Amps
------ Overhead[j llndgrd L.,a No.of Meters
Number of Feeders and Anipacity
-----------Location and Nature of Proposed Electrical Work. L fl"�C,71 7-11 4.C" "7`1�
............
table;ina ev)aivedbythelhs ector Wires.
No.of Total
No.of Recessed Luminaires No,of Cell.-Susp.(Paddle)Fans Transformers KVA
ire OntIc
No.of Lundnaire Outlets No.of clot"Tubs Generators OVA
--------------------
o.of L qxres Above o.ofEinergeE7n-ic��yyjighfl g
No.
of Luminaires Swimming Pool gt�udt rj
il� it Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas burners N_ d(T of Detection nn _
In Ltia_fing))tvices
-T(;t—af'
No.of Ranges No.of Air Cond, Tons No.of Alerting Devices
No,of Self-Contained
Na,of Waste Disposers
Totals, . ...... Detection/Alerti Devices
.. ......
l'oeal 0 Municipal
No.of Dishwashers Space/Area Heating J(W Conflectlon 0 Other
....................
No.of Dryers Reating Appliances KW Security 8 stems:*
No Mevic�sox:Eauivalent
NO.of—water N'_o"_._6f............ Data Wiring:
Heaters Ballasts NoofDevlccspr1 gurvalent
No.Rydrowassage flatltit No�of otors Total Ill., Telecounnuoons Wiring:
0�of evices E ulvalent,
....................
OTHER:
Aanch additional detail,i(desired,oi-asreqiii?,edby the Insl7ecto)"OfWines.
Estimated Value ofElectrical.Worli.: (When required by municipal policy.)
Work to Start:14'9 P-),S Inspections to be roquosted in accor&WO With MI C R.1110 10,and upon completion,
INSURANCE C6V—FE6T. Unless waived by The owner,no permit for tbe pc rforniance 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 sarno to the permit issuing office.
CHECK ONE: INSURANCE-ffif-430ND FN 01111-M. (Specif.y:)
Jcertffy,undef the ains,and )enahles,ofpeiyury,that the 1qfimnutdon,on this application is true and coinlVele.
Ff I I Al N m LIC.NO.-
Licensee: w Siguatdre� TAC.NO.:
(Ifapplicable,enter 11,x 7 1"inthAensitimb �Vine. el.No.Bus.T
Address:
z
C Alt.Tel.No.:-.----,
KGJ c, 1.47,s,57-61,security WoFFie-q—tores Depat-1-a-icat of Publf'c Safety 4", License: Lic.No. —
OWNER'SINSURANCEWAIVER: I arn aware that the Licensee does not have the liability insurance coverage normally
required bylave. By my signature below,I hereby waive,tbis lam the(clieck one El owner [j owner's agont.
Owner/Agent
Signature TelephojieNo... ...........
..........
ir�
r The Commonwealth gl'Hrssachusetts
Department of IndustrialAccidents
I Con revs Street., 8trite 100
lioWon,. A 021.14-2017
wwrv.nzass.,=zrV1(1h1
'G orhers'Compensation Insurance Affidavit:Biiii(jers/('oritz-aactoirs/ lcetriciatis/Plumbers.
'0 BE FILED W1111 I11F:1'ERA11'1"1 ING AU11 ORITY.
y Applicant Information Please Print Legibly
Name(13rrvizress/(Zr arrizGttiorrlltaciiva In a1) t ,q aC r t p 6 8"t P r
------
Address: cc,e.E, C t c�. ;
City/State/lip: a a u l'_ Phone 9-;�,�z i' 0 t
Are you an employer?Check the arepropriate hex. y
Type of project(required):
1�l ate aemployer with claaplaa.yccs(,full aaraSloa prat,-lime).*
7. ❑New construction
�243M a sole proprietor or partnership and.have,no ernploye eas working;, for erne in K. L._.l Remodeling
1� array capacity.[No workers'eouap insurance required..l
:l❑l ana a hnrrraacrwarar doing all vvorlc nrwsaall IIVo w¢rrlcers''craanp,insurance aee,i6reak-1'a
°). El Derriolition
i
IQ�,]4,�� Building addition 1 1<zm�a hrnxre+owner araal wa(k be jarring ue�utr uactors to r onalarct a�alP werlca crvra any property. r will
ensure that all contractors either have workers'aompe,ns ataou insurance or are solc P l.[2'TICCl"rioa1 repairs or additions
proprietnrw with no employees.
S.E]I am ageneral contractor and 1 have hired the;„rah-e�teawtraactors listed on the:aattaa faaral share?. 12. Plumbing repairs or additions
These sub cxrntrac tars have employees and have:work ers'comp insuranee>k 13.��oofrepairs
fi �
.�We are as corporation wail its officers have exercised them right of exemption per m(,1,c. 4.E]Other l
152„§1(4) and we have no employees,[No workers romp insurance requircal
*Any applicant that checks box ell nand also till out the section below showing their aaaarke r^'c ompeiisat,ioar policy itrtormation.
$1lomeownerrs who submit this affidavit inetacrating they are,doing all work and it hue out.,ide contractoa s must subnrit::a new affidavit indicating such.
lC;ontractors that check this box naust attac,hod an additional sheet,showing,a.he name of the sub-contractors and state whether or not those,entities have j e nployees. If the suh-oonirautors have erritifoyees they must provide their workers comp,policy nnnilyer.
I am an entpltrrer'that t.s prrrtaidirtg rwrrr•Icer,v'Conylensatlon instirane efor rtala employees. Below is the pallet'andjoh,site
Information.
Insurance("cranpany Nrtra€;:.
i
l
1''oli;cy#ar Self=ins.I rC !6 _ _.__ Expiration Late,
Job Site Address 'rt'y0"at«ktuArlw _ _._
failure to secure coverage as required under 1v GL c. 152,§25A i.
. t y fw
airAttach a copy of the workers'l oaupeas ation uwlrr declaration ation-page(showing i t he policy
punishable number a fi d expiration
it ration(late).
t,�1s�t1.o�
' d/or one-year iniprisonrnent,av well as civil penalties in the forua of a"STOP WORK ORDER and a fine o'fu'p to$250.00 a %
day against the violator.A copy of this statement may be fbrwarded to the Office 01111vestigations of"the DIA for insurance
coverage verification, j
u . true and correct.
"
r cr/zcre/ry ti tr av er tie arras arrrl r rtaltres rr rcr'zxr tltrrt flee irr arntadon provided above is
r'
G i ynatu �"
t3Jficzaf tasr rrrzl,r. Z7 o no wvr zee nt tfals area,to he completed fir city or town raficlal.
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City or Town; -.-__...__..._..Perinit/License'f/
Issuing Authority(circle one)
1.Board of Health 2.Building Department is C,"ity/Fowvn Clerk 4.Flectrical Inspector 5.Plumbing Inspector f!'
G.tither
Contact;Person: 1 -
Phone Ih
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