HomeMy WebLinkAboutWiring permit - Permits #11888 - 594 CHICKERING ROAD 10/1/2013 /
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This certifies that ...
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permit No.
BOARDDepartment qfflireiYervices
FIRE PREVENTION REGULATIONS Occupancy and Fee ilcciccd
(Rev, /01 lcavcblAPPank
L CTRICAL WORK work to be performed
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accordance with the Massachusetts Electric al Code(1w EC:),527 CMIt 12.00
(1.1Z,FA,V'PRI 'TIN lNK'()R TYPE'ALL INr,ORA,1,9X"l()N) Date: 10✓1113 J
City or Town t!j" North Andover _..,_. oars the electrical�r oji' acres
" �' the td,S`
By this application the undet sitoFea paves notice oIT71 or laer atateuatiota to perfor c described below.
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Location(Street&NLunbLIJ 594ChiclCeria� ad � �__,...._
Owner or Tenant Knowled a Clr iverse Telephone No, 97 ) �---_---_ Zf h �hl f l 1 I
Owner's Address
Is this permit in conjunction with a building permit? Ves No � (Check Appropriate Box)purpose of Building � � - utility Authoriaatann Na,
Existing Service Amps / wits Overhead El Unct rd
T ............ ...__ No,of Meters
Iff
Newer _. Amps / Volts Overhead No.of Meters
_ ()nd rid
Number af Feeders and Ampacity . .
Location and Nature of Proposed l+lecta ical WaVcrrh: Refeed all interior lights 11
d ceari(�fthe fiviaewing h4ble mqv be avcaiw d fry°the insdu:for tr,f Fftrcm
No.of Recessed.Lu�rninaires _ Now of C efl-Susp.(Paddle)Fans No,o at�a
Transformers KVA
Na.of Luminaire Ontlets Na,art"fiat Tubs
_ Generators KVA
Na,of Ltrittait°es wtttamin fiscal Ar've n a.a merEeny Jt ttt
utter Units ,
No.of Receptacle Outletsµ No.of Oil Burners FIRE ALARMS Na,of tortes l
No.of Switches No.of Gas Burners h•a election an
fnitiatin Devices
No.of Wastes No.of Air C:"ond Tons
�� No.of Alerting devices
No.of Rangy
e Disposer, 7 atal ntn��ons De t 0 ,el- ontarne
p eat nrn a 0. w11111,
p Local
Devices
No.of Dishwashers S aceJArea Hearin KW nn""i El %!
l C�onnectronherof
No.(if Dryers fleating Appliances tarWirin tents. 1„s
No af�cvtces of ntvafent l%ea,a titer W .. a,
Heaters S► ns Ballasts
-- __ No,of 1>ewuces or E navalertk: l�%
No.Hydromassale1Tathiaubs Noof Motors Total lilt etecontmaantcations rrirr a
l%
OTREE:
or as
(Whenrcgaairedbyeiij municipal olio required "Gdaaalres,vcrFrara�Wir�a
In d Estimated Value of Electrical W«aks o
fNSURA policy.)
Work to Start ASAP +�pectaaaaas tcr'tit.requested rrt accordance with Frr1p,C"°fCu.lt; 10,and upon.caanpBeticra7.
NC,E C�OVf"RAGf- Unless waived by the owner,no permit,for the performance of electrical work may issue unless the � �!
licensee provides proof of liability insurance itaeludin "completed operation"coverage or its substantial equivalent. 'l'he under-
signed certifies that,such coverage is in too c,e, and has exhibited proof of sauaac to the permit issuing office. �
CHECK ONEI INSURANCE' 0 BOND 0 C)'PHER [D (Spee;tfy;)
1 certify,under thepains and Penalties of per uiy,that the information On this OPPlical is true and complete.
FIRM NAME: Richard k3ras.(.,o.,inc. L �/
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1G'ro NO,: A l l b'2'1 /��
(Ifapdpdsccalrl,Wtllaana S.Flaclaarel � _....Signature I fC�.NO.:—
Address:
Licensee:_
.c nte,r i.e"rradat"do—the dra ease Turn—her liras.)
Address 905 South Main Street Mansfield MA 02048 Fans,"Tel No..
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per ,Ci.l.�.c. 147s.57 1�sea:urity wick acgaaiaes l:�elaartunerat cif public Salety""'S'"i icensc. L,ac,No. � lj"'
OWNER'S INSURANCE WAIVER. N aasra awvare that:ilia Licensee alrrcr arcya teuve the liability irasurance coverage normally re-quired by law. By my Signature below,l hereby waive,dais (regttizetttenl. 1 ttrn 4lte 'clacc one'D[�owner owner's a ent„Owner/Aleut ®
Signature _ p Crt l7l E: 125.0 j(
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The Commonwealth of'Massachusetts
Department of IIndustrial A cc idents
Office of In vesligations
600 Washing ton Street
Boston, MA 02111 R,
wwmass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Liectricians/Plumbers I
Applicant Information Please Print Legibly
NaMe(Business/Organi7,�itiogvlyidividual):___, V_tC"Pk
............................................
Address: MAC
City/State/Zip:_,_MP.P,5r_t6" , MA Phone#: _(_q?RY33S-5100
Are you an employer?Check the appropriate box: Type of project(required).
1.L!1 I am a employer with 4, El I am a general contractor and I
6 El New construction
employees(full and/or part-time)." have hired the sub-contractors
2. 1 am a sole proprietor or partner- listed on the,attached sheet.1 7. E]Remodeling
ship and have no employees These sub-contractors have 8, 0 Demolition
working for me in any capacity. workers' comp,insurance. 9 E]Building addition
[No workers'comp,insurance 5. We are a corporation and its 10.j��Electrical repairs or additions
required.] officers have exercised their
3. 1 am a homeowner doing all work right ofexemption per MGYI1 I LEI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12,0 Roof repairs
insurance required.)t employees. [No workers'
comp.insurance required,]
*Any applicant that checks box#1 must also fill out the section below showing their woW.Te_1;.mpemsation policy information,
t Homeowners who submit this affidavit indicating they am doing V work and then hire outside contractors must submit a new of indicating such.
lContractors that check this box must attached an additional sheet showing tile name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my eniployees. Below is the policy and job site M
information.
Insurance Company Name�_.
Policy or Self-ins.Lic.#: Expiration Date:...
--------------
Job Site Address:_591f 61&Lfs
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failnre to secure coverage as required under Section 25A of MGI,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 feral 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.
I do hereby certify under ains and penall' ofter'urythat e in/brmation provided above,is true and correct.
SLignaturc: e 10 -�v
Phone
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Official use only. Do not write in this area,to be completed by city or town offliciat
City or Town: Permit/License
Issuing Authority(circle one),
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
G.Other ii
Contact Person: Phone#,
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