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Home My WebLink AboutWiring Permit - Permits #12475 - 455 CHESTNUT STREET 6/25/2014 i i � jDate..ss�.......• � <s ............. FORTH TOWN OF NORTH AlU®OVER PERMIT FOR WIRING It ob 88ACHU5� This certifies that z... .�... a...... r."....�.�N. L t has permission to perform ........ .........`..... n<< wiring in the building of.......................: :.: ...................:.. .............................:...................... � s at .... ; orth Andover,Mass. Fee....`...:. Lic.No. " H c F ................ ... ......... .�(�7..........••••••. """" "" EC'IRICAL INSPE OR r Check#. 'c ` ; Commonwealth of Massachusetts Official Use Only Departmen F Permit No. 2 L+ `7 t of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) 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-PPdWT IN INK OR TYPE ALL INFORMATION) Date: J—v,,,-- 1-7 -Co) City or Town of: NORTH ANDOVER 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) 45�' 046-si-Auf sT' Owner or Tenant G/JALS tl"DKII-f Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead n UjidgrdF] No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: i26&0u(' .SC rle,, 5 0A) "46Te�( AjG AA)0 00IL06- 00TU7 //23jj(6 Completion of the fallowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lurninalre Outlets No.of Hot Tubs Generators I<VA No.of Luminaires Swimming 11001 Above Ei In- ❑ N—O.—O-FEmergency Lig ing grnd. grnd. Batter V Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones No.of Switches No.of Gas Burners No. of Detection and Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Np.mbe No.of Self-Contained No. of Waste Disposers Fi�nm : Number r].T9R§..........I.KW Detection/Alerting Devices Tota�ls No.of Dishwashers Space/Area Heating KW Local[I Municipal El Other Connection No.of Dryers Heating Appliances 1,11W Security Systems:* No.of Devices or Equivalent No.of Water 0.of No. of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Eaulvalent OTHER: Attach additional detail if desired,or as required by the Inspector of Mires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC Rule 10,and upon completion. 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 [I BONDE] OTBEREJ (Specify:) Icerlify,under the pains and penalties ofpeijury,that the information on this application is true and complete. FIRM NAME: 6eoO-G g T. a4smif qjj7 x>0.4 6,Tt4 &167cT%e 1C LIC.NO.: 13Z(0 3 Licensee: 660,z(,,e JF Signature LTC.NO.: Zia 9 32 (Ifapplicable, enter "exempt"in the license number line) Bus.Tel.No.: COY- 2 31`6 21 ui�� X4vv6—,0 uq Address: JXk(e)L/16CC-000 +),, Alt.Tel.No.: *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 am the(check one)D owner F]owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Information ation and. Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes.,, MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phonenumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LT C or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only-'submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tile Cwnmouwealtl of Ma..ssa..rhusetts Department ofTndustdat Accidents Q£fxce of 11tyestigatiou 600 Washington.Street Boston?MA Q21.Z Z TOO#617-727-4900 eat 406 or 1.-877�MAASSAFF Revised 5-26-05 Fax W 61 7"727 7749 TFFCFFS7cF YYl/]nct lrnTr�r�i.. Division of Professional Licensure: License Search Page I of I The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.GovHorne State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES .................. .......... .......................................- ............ ............................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:GEORGE J. HASSARD 111. REFERENCES& Business: DBA G J H ELECTRIC RELATED INFO SANDOWN, NH Disclaimer Regarding 111MEM Website License Searches **This Licensee has additional Licenses, click here to view them.** Glossary of License Status Codes Licensing Board: ELECTRICIANS More... License Type: MASTER ELECTRICIAN TYPE CLASS:A License Number: 13263 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 5/8/1990 Exam Date: 4/7/11990 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday,June 25,2014 at 12:32:01 PM. 0 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us)/public/pubLiceiiseQ.asp?board_code=EL&type class= A&li... 6/25/2014