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Home My WebLink AboutWire Permit - Permits #11773 - 113 CHESTNUT STREET 8/8/2013 o \� FEV ms �o Date. ..... :.. .... .. ...... ...... ,\ is ZEN DOVER TOWN OF NORTH AN PERMIT OR WIRING 110 RV 0Ei lop 4 s c fies that ....... ,,. .� ;. \\ i\ has rEnissioii tco perform ....., a��.,,.,,,� ,. ..,. � �� 0 g in the Wildin of......,,rCL..v. ...................,....... ........ ......wirin . ..... ............ 1cAndover, Mass. .... . ........ ...... low \ 101 lilt I, -. ININKM \ NO Check _ \\ ti' Commonwealth of Massachusetts Official Use Only Permit No. 12 7 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. iw] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(N1EQ,527 CMR 12.00 (PLEASE PRINT IATINK OR TYPE ALL INFORMATION) Date: T—9-/.) 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) Z/,3 CAtono- sr Owner or Tenant T , Telephone No, Owner's Address Is this permit in conjunction with a building permit? Yes P--ro-1-1 (Check Appropriate Box) Purpose of Building IZA&c,j tr t, 6,4+F4 fijit pNe+ce-- Utility Authorization No. Existing Service— Amps Volts Overhead [?'.- Undgrd❑ No. of Meters New Service 2-W Amps lt,,z 14 ° Volts OverheadF] Undgrd [:1 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following 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 Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei In- ❑ 'No-.-oTEmergency Lighting grnd. grnd. Battery Units No. of Receptacle Outlets q No.of Oil Burners FIRE ALARMS JN' o. of Zones of Detection and No. of Switches J No.of Gas Burners No. Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pump I A!! J.KW.......... No.of Self-Contained Totals: ........... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑F1 Municipal F1 Other Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.,of Water No.of No.of Data Wiring: Heaters Signs No.of Devices or Equivalent,___ Wiring: No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: L Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: jTV.,fs (When required by municipal policy.) Work to Start: - Inspections to be requested in accordance with MEC 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. C14ECK ONE: INSURXNCE [J-,Bt%qb [] OTHER El (Specify:) J certify, under the pains and penalties ofp erjury,that the information on this application is true anti complete FIRM NAME: :3t A Q,il C-4+u LTC.NO.::ko Licensee: &A cc i,� Signature LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: 2 N,!2-1J--3 L f Address: -74.- Loti!� me,4AL) AA Alt.Tel.No.: *Per M.G.L c. 147, s.57-M,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)F1 owner El owner's agent. Owner/Agent Signature Telephone No. PtRMIT FEE: $ SNX The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia UV Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t r(- Address: ct ' i �-( City/State/Zip: L. ,,4 0 Phone Are you a employer?Check the appropriate box: Type of project(required): 1. am a employer with _ 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/otime).` have Hired the sub-contractors 7 odeling 2.❑ r part- 1 am a sole proprietor or partner- listed on the attached sheet.* ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10 etrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12. Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lie.#: Expiration Date: -7 �o"' l Y Job Site Address: ), °-e f+ City/State/Zip: P a �/« t�✓�a�� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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 up to$250.00 a 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 t fy under the pains and pe Ities of perjury that the information provided above is true and correct. - Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - Contact Person: Phone#: Ohl LTH OF MASSACHUSETTS BOARD OF ELECTRICIANS; ISSUES THE FOLLOWING LICENSE AS A , } REGISTERED MASTER ELECTRICIAN JOSEP'H C GIACCHETTO z 32 LONGMEAOOW RD ?' CHELMSFORD MA 01824-2049 20426 A" 07/31/16 44727 e , a