HomeMy WebLinkAboutWiring Permit - Permits #12360 - 535 CHICKERING ROAD 5/16/2014 \\a x2g
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TOWN OF NORTH ANDOVER
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Department ire Services - l
Occupancy and Fee Checked
. � BOARD OF FIRE PREVENTION REGULATIONS [Itev,I/07.1 (leave blank) _
P APPLICATION F MIT ELECTRICAL WORK
r All work to be perf6rmed in accordance with the Massachusetts Electrical Cade(1`v1EC),527 CNflt 1100
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(PLL"ASS PRINT.ZIVMORTYPTI,ALL.r7V1 ORM4170X) Date: ,,Oo . l
B axisaCIicatianOOrdOtzt p r
t9 _.. ;__.__ ;9 the Inspector of I
rxota c this o her intention to O tY�wS:
�„ arf zm the electrarn°al rle described below. 1
( m )dry m�� ttt Location Street�Naxsnber t
Owner or Tenant .tt tr_ Z CI a__._... Telephone No.
._.........
Owner's Address
Is this permit in eosalua1 ion ith da building permit? Yes No � (Check Appropriate Box)
Purpose ofBuilding _Utility Authorization No.
�_
Existing Service.__� Amps ! Volts Overhead n lC,l'ndgrd F- No.ofMeters
New Service Amps _ d _Volks Overhead[j Undgrd[I No.ofM:eters
Number of Feeders and Ampacity
Locat fa nd Natu e of Proposed Electrical sealI Work.: �� 617..a z L
o
Con letion of(fi�e, olloinn tczbte rrd e a aivecl by the Iris ector of i.res.
No.of Recessed Luminaires No of C cild-Susp.(Paddle)Fans
Noy of Total_ _ Transformers K'VA
No.of Luminaire Outlets Ida of Hot Tubs� � � Generators KVA
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k Above _—i In- 0,'0fErriergencp'7�iglitirig r
Na.of Receptacle sOutlets No.of Cfxl�Burners ersrr rncl. ISat_tery TlnS:t
FIRE ALARMS No.cif Zones
No.of Svdtelles N"o,of G2S:fturners o,ofDetection and
Initiatiti l7)evices
mm 'fatal
No.of Ranges No.of Asir Cond. Tons No,of Alerting Devices t
..:. _.....,..�,....,..,. k �6
No.of Waste Dis users Ilcaxtl�urn l usu,iar r Ions i VW No.of Self Contained
p Total _ . 1)etectiarxZAlertin Devices
ualcspal
f No.ofDishwa.shers Space,/AreaHeat►ng I(W Local D D Other
Connection
No.of Dryers Heating Appliances KW Security xty Systems:
_ No ofDgyiecsax�I+.c�u►vale►xt
No.exf"Wrster Ncx,of Na.of f)sata Wirira
I_ eaters KW__ Signs.___.._:._...... ------ is_ N0.ofDeVCees or L usvalent d
No.TlyclromassageT3aathtulxs Nca.ofMcxtors f otal Il:lp_____ Telecommunications Wiring: T
OTHER:
_..._...........__...._.__.........._ ... ......... ...
Attach additional detail if desired,or as required by the Aspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: _ Inspections to he requested in accordance with:MEC Rule 10,and upon completion.
INSURANCE COVEAGE: Un Rless waived by the owner,no permit far the performance of electrical work may issue unless
the,licensee provides proof ofliability 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 Rf BOND 0 OTlflR C1 (Specify:) f
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zrzz taantz tze zdr t tcz ie irz aarrrzzrtz L[C NO
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IltlWl NAINfI� o tr
Licensee:
x t t�a e�e��� Sa?nsatua w � �t .: � �.:��w' _. LIC NO.,
,n an the l erase rG nalrer Zane.) Alt"Tel,No.: `� �� a
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(7foppltcable„enter`exet _ Bus Tel No
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*Per M"G.I,c. l d7,s,57 1,sec,:urrty work raelu:ares Department of Public Safety"S"License: laic.No.
OW'NER'S INSURANCE WAIVER. I aaart aware that the Licensee dos not have the liability inswunce coverage normally
required by l:a: , By nay signatta:re;below,1herebywaive this reiuirernent, f a:rn the(check:one)[_„]owner [ owner"s a rent.
Owner/Agent
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r 1'he C'ottatvtranwealtA qfHassachusetts
Ojjiee qffnPewfigatto s
00? ttshin ton Street
Roston,.MA 0.21.11 1
vim man. etvIdIa
Worliexg'Compensation Insurianc . ,tfidto lt:: uffders/ ontractors[Electricians{Phunbers
A01311cani.jtforoatition _ Please fflutLog%bl�
NaMc(13usi-nass/tJrgaarizationffiacixvidn ,).y.n._&. �"�'�:�' "' ""� °"� &".._.._W�,�
f
Address: _ ,p _______
h ` t` mCity/StafCOP '
are
,t yrm nn oruployer?Check the axppropriaate box. Type oi`�,ryxc�je t(x e 11uxre d):
1.,R-1 1 am,a ontployor with _( 4. F ��atat ra g na ai c ol,dractor and l6.
.❑ I Ana,p a sal have Ixrx ucl tiro a�xfa oosxtractaerr � �I�ow ur7xt 5traxutlr.�n
yews(full sxac3/az sari tvr�u .:*
e proprietor or partn cx-
la rtecl uax the srttacloed shee�fi. �ld ernodr limp, 1
ship axxd`lave no employees 6 hesc s,rala cant actors have, 8. ��Doi.loS�tr.a;u
wanking forna.ainaaxyuapac:ity, rrcwa:kexa'ccar l> ins2rran.ae. 9. ElBoildingaddition
[No urorl exs'COMP.xnsuranae 5, `o are as corporation and its
xegralxed.)
officers have exerursadtheir 1.0, Electrical repairs or additions
3.1 l am a homeowner floJnb OUWOfk right of exar pliollper WI 1,1.�,_ E'lu .bing repairs or additions
nxyself EEO camla. c.:152,§1(4),anrdwehavano 12.Q11oofropairs
iusxuaireere xlxed. 'r einploycus,[No workors' �
� � 13jj t)t6ea;
comp histrrancorequired.
aAny applicant that shacks hox fif must also fill out tho section,Wow s u v ng thalk w 7zkexv'c oaula�a�G t[rz�polfcy r"nfarzz viion,
f3lo neawnera when saamztihis aft"idavitindioaiirzgthey ftra d9in r oilwork'and then bare Outside contractor's mmt submit anew afu,davit Indleating such.
tConixautara that chekthfs hux must attached aa£the stilt-rontracturs and theft wormers'soap,policy inthxmation. 1
t altz rin employer th(d fs providing;workers'compensation ihvirrance for my einjilqpces. .Below h tlae,laolley(Hid o,&site
information. r
lastryance(",mpsaayNarae:_ __._._._._------------------
Policy i#or Self ins.Lie.14:_ __._..........__.-...._.,.__.....__._.._._..__.�.........___......__._......._.........._......._.__1rxp�stxarr l.7rate:
Sib Sxt:Acicress; � _.P Y/State/ZI" p"» ° a nra r
Aatach a copy of the workers' (sltowving thu policy number and expiration date).
Failure to secure ooverage as regpked urodor Section 23A of MOL c 152 can lead to tlia raxapositiora.ofcriteival,penalties of a
Paaa.e°ap to$1,50 R00 and/or crne�yeGrr huprisonaaeat,a'well,as cavil penaaltxu r in the harm,of a STOP.WORK ORDER and a fine P
of tip to$250,170 a day against-the violator. lie rrdvsse°d thaat o.calay zai:thi,a,.,tait:m.errtaxtay he;tarvsarded to the Offzoe oaf
lavestigations oPtho MA for iisuranco caverago vorfficatiarr.. f
cto Xieretry r�cr: p^ rt� tlitczra correct,
rt ae.lcs crr"rrjraa y ttaart Me rrarrrixrctin y�rrxvirrd tztinv true a
Sxxaatc�xeaa . . 17ate.
Phone .
lJfficteal use orzly. -D raat write zra tFels rrre ,try be c rrrxz rXete�l y city va^tosa�a >f e irzh
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City or Town: Permit/License ii
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f8suingAnthorxty�(circle one):
l.:f59ard ol":ffealtlt I l3uitrlin Delaaxtment 3.CifylTown Clerk 4.Blectrical hispector 5.PlufablogIhsliector
6.Other __ .
4"talrtsr o°sole.: Pho00 ,, ,......,„ ..,
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