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Home My WebLink AboutWire Permit - Permits #11734 - 75 CHESTNUT STREET 7/18/2013 z W \ _ ige 011 I` Q ..... .., :.. .. .. . .............. Date � o I �I TOWN OF NORTH ANDOVER \ PERMIT FOR WIRING01 MINN \� s O This certifies thaty g \\ .................on _ . ... ...�,_..,.,.. _ __... •aa.xa+ • c ENK BOOM pe sQr to perform wiring in the build of.........., RNOR \\ kM at ........ .............. ........... ..... .................. . __. ...,.. u driver, bass. Fee. ............ ..Lic. No. .... . ._. . .. _ ._.�a i � .......................... .�: ... WE............... \` ELECMCAL INSPECTOSE s O AMIISMIN Check# ` I s ,\ All `\ Official Use Only Commonwealth of Massachusetts epar°tment ®f Fire .Services Permit No. � / '; Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: L,) 01 Z /, City or Town of: NORTH ANDOVER To the Insp etor of ices. By this application the undersigned gives notice f hi or he intention to perform the electrical work described below. Location(Street&Number) ., yC Owner or Tenant l- �AzA 6 lh ra.L 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 ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead[-1 Undgrd ❑ No.of Meters Number of.Feeders and Ampacity I Location and Nature of Proposed Electrical Work: c I! llrl el Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE.ALARMS No. of Zones No. of Switches No.of Gas]Burners No. o Ind Initiatiur Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained -Detection/Alerting Devices Totals: Detect_, No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No. of Dryers Heating Appliances KWSecurity Systems:* No.of Devices or Equivalent No.of Water RW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total 11P Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if 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. 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: II�ISURAN E BOND ❑ OTHER ❑ (Specify:) I testify,sander th ins sail naa ties ofpeJ that the information on t1a' ication is true and complete. FIRM N X / 704-e LIC.NO.: ` V If License . its „�° / Signature LTC,NO.: (If applicable, nter " mpt"in the licens number ne.) Bus.Tel.No. �, L :w7 ( Address: .Ca. e 11,5 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety'IS"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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $" /l The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Narne(Business/Organization/Individual : t C Address: m City/State/Zip:_ _ ,)o ice'° Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. lain a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 (�pudding addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1 Electrical repairs or additions 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' comp.insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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 far my employees. .Below is thepolicy and job site information. Insurance Company Name:. Policy#of Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL 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 f insurance coverage verification. I do hereb ertr un er Ir ins ndp a es ofperjury that the information provided above is true and correct. _ Si atur , Date- Phone#: F'Issuing e on1y. .Do not write in this area,to be completed by city or town official. wn: Permit/License# thority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: