HomeMy WebLinkAboutWiring Permit - Permits #12779-1 - 565 CHICKERING ROAD 10/19/2015 r i A�t
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COmmOnwealth Of Massachusetts
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Ipe;rmit'No.
Department ite Services —
()cnu atacy and Fee Chocked
BOARD OF ACRE PREVENTION f LMLA " N :R.cv.I/O 1_..__(leaveblrcnk.,
APPLICATION ELECTRICAL
12.0 All work to be perfcprrneci in ae a���azce with the l�ssa.cahars> �( � 12,.p0 1'
(PLEAS 'P1NI Llk�Jtl?CS C11'L 1 ' .hl� �"
.). ft rats Electrical pal Code t+C ,S27 C
Y pp ersr ne gives notz for h .I ca C e I t Caeetiar a�"WireRs:
� this application the rr � 11
p gal work described below.
x or Town o NORTH��ANC
nci "cu,o.0 zzs creharznicntrora ter ertorzn cic,ctrzc
Location(Street Number) S � r
_. r
Owner or Tenant .a __._..._..._._ T
Owner's Address
..s this permit in eonlrr tr '�h a b zlciMg nzrt? Yes o [j (Check Appropriate Box)
Purpose of fluihling t Ut.ilrky Authorization No. a
ou rt w
v.
t
uw Surcrvice _ ..
xistizrg Arrz rs iC l u Volts Overhead � L � No.of Meters
volts O'verherrrl d.
Number of Feeders and mpac.r � ! � i 1Trrcl�r i � No. Meters
r
p �"
Location arzcl Ntrtxzra of Proposed Elactrrcal Wore
_____ __. __... _. _ tarlrtzaza0/t6iccC/cr in rble atz5�or1nrarsvedbytFaeXAorrFVires. �.
r
of Recessed Luminaires N .of Cell Susp.(Paddle)pans No of Total
No. rrrirzaire Outlets
No,offlot Tubs Generators C:V r�
xninairas Swirraruizrg Poal ' �"" a laa-- u.crt nzargerzcy rg rngr rrd. att ceptacle C)n'tluts No.o'fOil Burners t�:CRE ALARMS lVa.nfi bonus_._i�tches No.o�ll as,Burners fro,ofl)etectionrand...__....___w hitiatin Devicesar us 1'o'tal
No.of Cozad. Eons No.of Alerting Devices
No.of Waste Disposers heat Pump 1N.n.rr Viper ^Torre Ifs No of SeM--Co ntainud r
Totals. �.�. .___ UuR.action/Aterti�Travieus
No.oi`Iltiv'lrwasheas 5paeelAre a,fluatrng I,`C'W i: rarzl Wlunicrpal —
[j Other_... ...._,___ connection
No.of.Dr Dryers IOW licwztigApplzaaares ICG1c SaeuritySysterns
y n 1
—--_-____. _____._.... ai )e0ces or 4 urvalant
No.of Water _ No _cr._ _ __...._.. _W cl _
Heaters No of Data Wiring.
_ Smarts �._.._Pallastw __. _....___._ No.of Devices o�trivalent
No.flyclromassage bathtubs No of Motors Total I'I'lp Ic:lc�or'zrmunicaitioiis Wiring: p
rafDevices or E, uivalent
— „
_ Attrxcla cx�dstrtrerrzezC cTerrzrl r�`rXesrrr rl car c�s�required b)+the Zrrs�eeBor of IY"tres°.
Word toeStaat; u e,,r �'1 Wor1c p p i,
' ValrreoTlleutrrc<r (Wlrcraeaccarciacila'
rs ec.tions to be requested ested in ncc with 'pal policy.)10
rruclurxa yrrnunzcz lzu
Ckulc
__. the no perrnitt�orthe perfrrrr rrr of� niuxrcrncorn�pltation.7NSU1tAl CE C OCaTItAC�1+;: Unless waived by 1 1 electrical.work may issue unless
the licensee provides pz ool of liabilityr insurance nrclurding;"completed operatro0 coverage or its substantial equivalent, The
undersigned certifies that such cover ois in force,and has€,xbibitecl proof ofsanre to the permit issuing;office.CRE ll�
X is trite r t
cert¢fyr,arrrrXc�r tlrr,�az.. w ns and o ) �_� 0 t ILtl:tt (._j (Sdae^c rty:)
CKONE IN51tt/t1'3C
rr�Ph � rraitrar arethisapplicationapplicatrite and rraarr.e �7��°d"
I A�I.f rlc.11. t
tiIt.1C .-: f� LIC.No.:
Signature
a7plea era the Crc6rr z nh r C e
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5
se J3us Tel,No.:r
er t C N __
security work requires Department of Public aa ty License: 1rc.No.INSURANCE WAIVER: fam aware that the Licensee elo s not have tape lr rlrrhr.ty insurance coverage normally
z egUirec b y law. 13y illy signature below,I hereby waive thi.s a eq uarr"enien t. �l�arzrp
Owner/Agenttlrc (check one)Q owner El owner's agagent. f/„ice
Signaturelr� rPiIXT, ist.
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I`ele phone No. ��
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the Commonwealth of%ssachus°ally l
"Workers'C onnlrensaatiaynr insuraaucelAfli.davit:IlariiclarsF(;cr
TORE FILED WMITHE
A plarse I'rint :Gcrblw l ialicant fir
xanritiara i:1E E3usrxtcssB(7r araar ar l raelrvtc
m
Address: _ __ _ _.._..__
_ .. ......_ _..._ j
�� iailon it (a r
C.,lty/ ill /CI�I i
_ . . ......,. _ __... . w _._.;.w.,......
1. yo a rr a en ployer?6heclr the nppararpra�Xle 1r<rx° 1 I ype of project(required.);
.TC arrX axr 0Xr1 ` rr ^
ployer' rt- cnx�irayecrr(fitllaadlorprrl,trrn�).'* B f.I�.e 66usfn' ion j
7 h„ lde.u'nvcicliil ��
any capacity.I,11'u workrrs'csrsrnp na to antra xquirul]
_.1
9. 17eauolition, t�
wner doing,
4. I u a laanregw er and wrlll work tr laasasXryclrtX[No
� itur to cerrra.l rG t ill a,u znce required
10. (._�Building addition j
work tart any Pr:otreu�ky'. C.will f'
eusxrollaaYalloasxra tanscativr"have,wuak,ezw curaap sationingunrxceor,arcwile, It Electrical repairs or°additip'ps
prrcprietcn's with no einpla7 es. ] � repairs or additions
5. S aarn as general confractpr and I have hired ilia atrh-contrartar a listed on,dio aattaclaeul sheet.,
��.� 13.9uav warkrr caruip.ara ria ca r.'t ]'l,ir l're airs
14. ( Cl7er
6.[J We area aarpazaCian and ifs.officers have axercisrd their riprk a ox.onaptlon pitNCl ;.
1.52,§1(4),axdwehav¢nn nnlalayees �Tlaworlds uXtap Xnsaaanteacyusucl} ;';
... _... _. .......
*Any applioanrL'tF at uhealcs'box 41 rna st also fill out the section below showing their war ke r c�omponsat�io�n,polac�y infuirnal:"rrtn;
t.401neowxrerswhosadrrara• all work lrautoz:sniuslssubtriltanew davitindicatangsuch.
Gontracton that checkthis b ainnust alluo�a,c ruk additional sheet showing the aan hla¢ e sub-�a onty
S p
#� a G the ar,arsa�¢r of llre suh 1 aniaactrxs arnd sttrto whrtfiea^or ztot thetas wrzfityesto have
p p y y Provide as +uaetf pert uy XrurrilarX
ern layees If the s ah c antrmctrrrs have x a lu ra s they rxulst ...... thraa, wvrlcc
fain an compensation.tion..invur anc:e.for Y,4v err ply yee%s°. helow Is the paltry and roh site
inforination.
lixsrzrance C.orrnlntrny lanrc: _. .... _ _.._.....__..... _._ _...w....... l%
Policy#or Sal -ins.Lie.lf�._ ....... �__ _...._ lax..piratiunDirter:...__.._.._..... ....
lob Site Address: _..__.._......_._ _
A.ttach a slay of the workers'earxnlroerisalaan lra:lae.y declaration page(sla.awvrxt};the policy nrarrnlber and expiration liars).
i�
Failure to secure coverage as required ran€ter 01 c,.151,§2,A is as c r lrrrinal violation,pirni.shabler by a fift up to$1,500.00 L�;
and/or one-year inrprisorn ic.na as v c.91 as civil,pernaattle a in:the forru of a S SCf:E'WG K()CiDER arud a fine of up to$250.00 a
day against the vialata:i.A c rrlry offbis sta temeni na,ay be forwarded to the Office of frivestig6tions o:Ethe.D.IA for insurance
coverage verification. '
X do hereby c erlrfirrarXerr tltr aczirr s arxrl pt raltzes^cd f`perr ary t/zat the rr 'oil aticrra p�owrded rx/,rawc�rs tires ara�d correct �i�� `
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Phonet#: �. ~?.-�_.
Official use only. Do not write its,this area,to lie completed liy city or town ofJecIaf
City or ["awns__. ......._. .....................-- - -----permit/lAcenset
__.-_...__......_.......
.....
fssuing Authority(circle ones
1.:lloarrd of health 2.i:iuilding Department 3.C ity/'h"avcu Clerk da Electrical Inspector 5.Pluxnibiug Inspector
6.Other
Contact __....._...___...__...-.._....___.-_....-..__._._ _ -_.__..._._.___._._._ I'd:icraaeiP:.
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