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HomeMy WebLinkAboutWiring Permit - Permits #13181-1 - 565 CHICKERING ROAD 3/14/2016 (3) .,rrrrr�r//fr %///i�• r•, /���(�����r ���,r. /17fY/ll/��/�/ �j/ w. / %s fir PERMIT FOR WIRING IMF % has permission to perumn .1--l.",/ gi�pp,' g� at a c li-Ai ucl<Ymm, Mass. "g// a / / Fee �"J ............. 1�6', r ll _.. %W/ __. a� i 01 p Commonwealth of Massachusetts _...(I fdclal'l r e 0niy �° l'ezxaait Na. Department Fire Services Occulmnoy and lace Checked BOARD OF FIRE PREVENTION REGULATIONS (leRi aveblattk IRev,1f�71_,. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK EAll work to he performed in accordance with the Massachusetts Electrical Code(M ),527 CMR 12.00 0"LUSTP MTIN AFKOR TFPFl AIL J'N:T'ORAM ON) Date: j City or Town of. NtJX R ANDOVrM :Co the Inspector of Wirav: Location(Street&Number)g rxa2�ioglVeSe� ha r�tetlt aarParxaa the el ectriaal.warp described below, i B thus application the u Owner or Tenant t M f._...______....__._ _. _.._.___..... TeleplioneNo. Owner's Address Is this permit h)conjunction with a building permit? Yes F. No (Check Appropriate Box) Purpose of Building,.. Utility Authorization No. p - " Existing Service______ Amps 1 Volts Overhead[.] laiadgrd E] No.of Meters a New Service -_. __..._. Amps _ _/_ _....__-'dolts Overhet d D 1Tlndgrd� No.of Meters Number of feeders and Atnpacity s Location and Nature ofProposed.'Electrical Work " ._-. ------ Corn la taern crf tlae er11owira table ni Ins ector a Wires. t ffN of RecessedLuminaires Na.of C"ail.-Suslr.(I'acldle)1 ens No.a£ Total 't"rransformers KVA Outlets o.of(lot Tubs Generators KVA �-- 5wirumiu foal Above (r-i'itt= 0.0 .off"+�mergancy �g rang rrrtrlw ..._ rnd. Batter Yjnffs__- ... ._ ,.._._- _._.__ No.of Receptacle outlets No.of Oil Burners - I+'I3t�ALAItM:S Na.of Zones � No.of Switches _No.of Gas Burners� No o£-. etec�tTon End Initiatin 17evices of ir No.of Ranges Ite�tl a�m CrNumber lonotal ICE......,, No.of Self Cantahtices Ions No.of Alerting No.of Waste Disposers p .. ed i at rls. _ Detection/Alerthi Devices No.of(Dishwashers Spacc/Aa ea hing eat KW I acKal[� M nic►pal Outer _._. ._._...�_.._..._ C"atmcctrarz No.afBlfeaters _._._. .....__ .. I'lctztan r Appliances fVa er£ ecia y Syystems.• - - y pl It.W Na ofl3evices or T uivalent No.of"Water Na.of ___._..._,_...-. KW Data Wiring a _...._._ _.Slanw w - Ballasts No of Deyicesorgq!tvalent l No.Hydromassage Bathtubs No.of Motors Total UP I el ommunicathons Wiring: r ._._.____.__..._._._.__......_.._ No.a£IDevicesart; uivalcnt HER. OT' Attczch a id-tacrrasal cletxai z�c7e it a�cX car as re�asire d by the:Inspector of Wires. i Estimated.Value of Electrical Work. _ � (When required Dry municipal policy.) Work to Start inspections to lee requested in accordance with MBC Rule I0,and open completion. " INSURANCE CCDVF 12ACx11. Thiless waived lay they owner,no permit for t the,performance ofelectriaal work xnay issue unless the licensee provides proof of liability insurance+including"completed operation°'coverage or its substantial equivalent. 'Z'Irc undersigned tch coverago is in tbree,and has �aabited(yp��t�otcfiz tnctothepermrt issuing office. CHECKNE:;ISTilEc 130m) [-] OTHER X certify, JS o perz t trt the err rirrtlrtotlts application s trite and complete.FIR NAV LIC.NO..TT1 ... , Sr r aCare IAcensce. .. _.. ,.. Busff mlicable, na.xemjrt"in the iceensemherliae)Address: Tel.No.O.:,r *FarOLc.I AltaLel No.: work ra utres Ie artncnt of Safety ,S" License: fir"a a c" ` Lie.No. _ OWNER'S INSURANCE WAIVER: I aru aware that the Licensee does not have the liability insurance coverage normally �j required by law. 3y'ny si rat'twe beloNv,I hereby wtiive tlrr.s rc. uiretraerrt, lam the(check asze Owner/Agent I'c e rlranc aaica,___..-._w..__.__._ " " AZT tF�� 77 a carat. el ( ) owner owner's Signature I ram! «aaaartr� to „HIM The Commonwealth of asserc°hzeselP,s IN Department 1 Congress SY�°a�^cA����tilim .[fl�1 Boston,AM 02.114-2017 W»�� www ntnss.gov/dia Wakel,s"Compensation Insurance affidavit:Bill Idera/f',on ractors/Ie triciiiiis/Pltunbers. TO JII+,FILED"WI H rl"ii;1?I!".I314f11"°d'ING AUTHORITY, 1"�iallle Applicant.dtpasliinceasnsJtt r�7 arrrlzmataian/Indivi r Please Print fe bl tAddress ` /. City/State/Zip; 0/ P tllae :� Are you an employer?Check the appropriate box.- — Type of project(required): ed): l�anraompluyorweGtx_.._�""_...._�nalrlcrycos(full a�aclluxlr�act-tiu�e).r 7. �I`�Tetwct7nstt'ttcttolt. i 2Q I a�na n sole proprietor or partnership and have no omployees eva>rking for me in S, []New construction any capacity,[Nov�workers comp insurance required.] 3.L-1 It am a homeowner doing all work myself.[No workers"comp.:ansus<u re reclu�ir<,d.1 t 9. 0 Dem,olition r r 4.0 I ears a homeowner and will be hiring conYaach'rrs'Io conduct all work onmy property. a will 10 L 1 Building addition cnsure that all contractors either have workers'cornpen9ation insus amen or toe soles .11 Electrical.repairs or additionsproprietors with no employees, Plumbing repairs or additions[ t S,© contractor ana a general uoactar and I have hiredhiredtheu sulr usnbactoa ar Cho attae3secJ,.beet;. l2. Those sub-contractors have employees arid have workers'comp.insua in e.t 13. Roof repairs 6.[:]We are a corporation and its officers have exercised their right cat exemption per lrJ' r. K E]Other *An applicant that checks box##1 inust also fill out the section below showingtheir we i � policyinformation. I52, 1 4 and we have no eon alo ecs No workers'comp,insurance zc uired f Y"pP rekc,rs corn aensa�atiaars t homeowners who sabstirt this allu9avrt indicating they are dairst„all work and then hire outside cunkr aotnrs must submit anew affidavit indicating such, tCurrtacturs that check this box must attached an additional sheet showing the name of the sub-coni a a ralors and state whether or not those entities have employees. If"the sub-cbnlraaturs taaave employees,ihery most provide Chen waa'kr�rs"aomis.Irolicy mzzaakoer. I arrr an emplaye>r that is pioviding luorkel'S'c.,orraprrrsation insurancre.fol°easy etnp1byec, Mdow Cs the policy Und job site Information. Insurance Company Marne: Policy#or Self iris,I,ic 4l r2x iratton'Date l ._. ,_.._. _,._._.__ p Job Site Address. _....___ City/State/✓i�p:_ M, Attach a copy of the workers'cirmpepsaton policy dedarFation page(showing the policy number and expiration date). j Failure to secure coverage as required wider 1'v'C( L c 152,¢2SA is,a criminal violation prurLshable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form o1,a S 1°C'7P WOktf;ORDER and a fine;of tip to$250.00 a day against the violator.A copy ofthis statement may be forwarded to tyre;Office of Investigations of the IIIA for insurance coverage verification. I rio Cereby certrfy the pains pndCfes oftrcrley that the or aatrf)at�ovzcet above Is t ae and correct.- .a �M' 0Jf1cial use onCy. Do net write in this area,to he complc ted by city or town official, Yid City or Town: PerrnitJEicensc Issuing Authority(circle on(-): 1.Board of health 2 Building Department 3.Cityrrowvn(:".Jerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ------------ t fi Contact Person: one f� ii, j/ t „ f �ria