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Home My WebLink AboutWiring Permit - Permits #11812 - 200 CHICKERING ROAD 108B 8/26/2013 k Date F TOWN OF NORTH ANDOVER PERMIT FOR WIRING Q�CHUa� This certifies that` ...... R...................... has permission to perform .................. ............. wining in the building of ........................................... at . .................� ,North Andover,Mass. t GO, Fee.... .. .... .........Lie.No ..�.... ......... ....... ........,... ..... ..;.......... I Check# LEC2RICAL�NSPECTOR I (f1MJn0nxea19-/Majdac4u4altj Official Use Only FPerniit N 2epadnwd 0. Occupancy'up Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] Cleave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: \-\ 4 I-P�,,% NYNaI-i�N 111111'r . To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) � bL,, ts"if T Owner or Tenant Urv, Telephone No:w Owner's Address 14 m"4- Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Put-pose of Building Ir"'1Z. "') Utility Authorization No. � Existing Service Amps Volts Overhead El Undgrd[:] No. of Meters New Service Amps Volts Overhead ❑ Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: V,,) CAtf kLat'6w Completion oftheLollowin table may be waived by the Inspe 11'es, No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No—._0 F otaI Transformers KVA No.of Luminaire Outlets No. of Rot Tubs Generators KVA Ig No. of Luminaires Swimming Pool Above ❑ (11 1 :01 911� (11 mggrnd, ❑ ir!n0d. Batter Units No. of Receptacle Outlets No.of Oil Burners FIRE, ALARMS No.of Zones No. of Switches No.of Gas Burners No of-petect"on and Total Initiating Devices No. of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Number„ Tans,,..,..._ 0"ta' in'ed Devices No. of Waste Disposers Totals: I Detection/Ale rtin Devices No. of Dishwashers Space/Area Heating KW Local unicipal Connection 0 Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No. of No. of No.of Devices or Equivalent Heaters KW Data Wiring: Signs Ballasts No.of Devices or Eaulvalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications u-I! No.of Devices or E ui a llient fell OTHER: Attach additional detail i1'desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion, rq) INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance 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 same to the permit issuing office. CHECK ONE: INSURANCE R BOND r-1 OTHER F1 (specify:) I certify,under the pains andpenallies ofperjury,that the information on this application is true and complete. FIRM NAME: t v t LIC. NO.: Licensee:"'I"\,1114 I%01�+NJS A-4AV100V%r% �AA Signature LIC. NO.:.L I (1j'applicable, enter "exempt i-n the license number line.) Bus.Tel,No,, Address: %W r, Alt. Tel.No.:-4QI *Per M.G.L. c. 147,s. 57-61, security work requires Department of Public Safety"S"License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I all, the(check one F-1.owner El owner's agent. Owner/Agent Signature Telephone No.__ PERMIT FEE. $ I ck-cb The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 6#0 Washington Street Boston, M4 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/)Electricians/Plumbers licant Information PrintPlease LeWbal Name (BL]siness/(-)rgatiization/itidividual): (b IF— tol hp, Address: J City/State/zip. A ��VV Phone At. �-J t�� Q -L6—� Il- Are you an employer?Check the appropriate box: -- am a employer with 4. F-1 I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. E] New construction 2, lann a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have working for rne in any capacity, employees and have workers' 8. ❑ Demolition [No workers' comp. insurance comp. insur-ance.1 9. ❑ Building addition required.] 5, E] We are a corporation and its 10. Electrical repairs or additions 3.EJ I am a homeowner doing all work officers have exercised their I 1J9 Plumbing repairs or additions rnyself. [No workers' comp, right of exemption per MGL insurance required.] c. 152, §1(4), and we have no 12,n Roof repairs employees, [No workers' 13,0] Other_CL(Al 4---_ camp. insurance required.] 'AM applicant that checks box#] must also fit I out the section below showing their workers'compensation Policy information Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such�k.ulltraclors that check this box must attached an additional sheet showing the narne of the sub-contractors and state whether or not those entities have c1T1P10Yee-s I I'the sub-contractors have employees,they must provide their workers*comp.policy number, /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name:mAkx&A-t,-%- fi�Yl Q S a Policy 4 or Self-ins. 1-ic. Expiration Date: It 0 Job Site Address: Z,ez,,C:A Vz V t City/State/Zip. -- Attach a copy of the workers' compensation policy declaration page(showing the policy number an.d expiration I I- .- -date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of LIP to$250.00 1 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 certif y underthe ams and penalties of perjury that the information provided above is true and correct Date h� 11 F0JJicW use only. Do not write in this area,to be completed by city or town offmial City or Town: Permit/License# s-s-tu i Authorityn-g-1 (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person:— Phone#: I i III I i 40M1VIQNW '. Lt Of= M _ � ETUIS, - gut At F.€3Lf_(14dl U EN GO Af - �sTV fiES au ME E LE CTR f C f W. � a` JHGAAS A LAMOUf2EUX U , Bpftf�f t�tGTOfa r # .Q2$86-42Q$ : YAW i rt?ttttQNf�1EEAL? F (Vf $SAfT"€�a�r. :... this B4)AEtt? EL t C l Rt5 {' f SS ES aE F�I,LSON k#QE�SE AS A . #S f<RE4 ASTER°f LF, #C i Afd Q GfM 'LfJ16}I+#G fs #fAT I N,G; T QMAS R f: ti fff,EUX f w 3, ALL#S #Ct/��t!#E ARRI.NGTON. , #i! Q28Q6 42�$ _711b7 o7t1/ ,,