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Home My WebLink AboutWire Permit - Permits #11411 - 21 CHAPIN ROAD 2/14/2013 i - - � ..\ .g l \\ ae,,..._3 �� IS O NIMMIN glIm r IN '•. '�'CTOWN OF NORTH \ ff Ml _ \ ..... .. „ ...,..., is certifies that .......... Ml IN, . ......... ....:.... _ << �\ MOMS� � . Al �a... _..� � . haser�ssor� o gerfcnn _ ,. �, 0, O wiring i t M \ z NorthAn Mass, LIMLL o at IN I�� . No. ................................................... Fee. ..,. _..,�,_ Ei zc LNSPEC OR 0 IN CheGk # EIN 2 (flImmonweaIR of M"aclwetb Official Use Only Permit No. Apart.d 43Ire Occpanc y and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]u/071 (leave 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 INFORAM TION) Date City or Town of: To the ZInspeZctor �Wires. By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) L� eZ,2111�cl Owner or Tenant ..':F124-/w 7---Ilvellk Telephone No Owner's Address Is this permit in conjunction with a building permit? Yes E! No (Check Appropriate Box) Purpose of Building-t. Utility Authorization No. '146 Existing Service Amps Volts Overhead ❑ Undgrd Q No.of Meters New Service Amps Volts OverheadEJ Undgrd No.of Meters Number of Feeders and Ampacity IN) Location and Nature of Proposed Electrical Work: 6ek�- �Ope ompletion of the.Lollowing table may be waived by the Inspector of Wires, No.of Recessed Luminaires No.of Ceil.-S-asp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- M No.of Emergency Lighting grnd. arml. " Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection an — Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump !!giber Tons M.- KW No.of Self--Co—ntained Totals: Detection/Alerti"3,Devices No.of Dishwashers Space/Area Heating KW Local Municipal n Other Connection No.of Dryers Heating Appliances KW ecurity Systems:* s Devices 0 1�g vices or Equivalent No.of Water No.of No.of N .0 - c I Data N�irl Heaters KW is Data Wiring: ....Signs Ballasts No.of Devices or .ouivalerit Motors Tot I H Telecommunications No. Hydromassage Bathtubs No.of Motors Total lip Wiring: No.of Devicesor E uivalent OTHER: A ttach additional detail of desired, or as required by the Inspector of wires. Estimated Value of Electrical Work: (When required by municipal policy,) Z�Z- ,�- X 13 requested in accordance with MEC Rule 10,and upon completion Work to Start: Inspections to be 7 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 BOND F1 OTHER F1 (Specify:) I certify, under the pains andAlties ofperjury,that the information on this application is true and complete. FIRMNAME: Aries Electrical Service and Controls LLC LIC.NO15650a Licensee: Nor and Michaud Si natu 3459-Z—e (If applicable-en ter n'te"r "exempt"in the license number line.) ......... Mg , 1C.NO.. Bus.Tel.No..- q T B 687 0 544 Address: 290 Broadwav suite 117 Methuen ma 01844 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 FJ owner 0 owner's agent, Owner/Agent Signature Telephone No. PERMIT FEE.- $ The Commonwealth of Massachusetts ri Department of Industrial accidents it Office of Investigations $ 600 Washington Street Boston,Mass. 02111 www-Mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib!y Name(Business/Organizationflndividual): A1uzsL CAL SERVICE AND CONTROLS LLC Address:—.290 ,B:RoApWAySjTTTg �4 117 City/State/Zip: -Methuen—ma- 01844— — Phone#:......9 7 g 6B7, Q544 Are you an employer?Check the appropriate box: — Type of project(required): I. I am an employer with .1 4.0 1 am a general contractor and 1 6. 0 New construction employees(full and/or part time).* have hired the sub-contractors 2 7 am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no ei-F-pic!yees These sub-contractors have 8. 0 Demolition working for the in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.1 9.0 Building addition required] 5.0 We are a corporation and its I Ojclk ctrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their X _Kle myself [No workers'comp. right of exemption perm MGL 11. D Plumbing repairs or additions insurance required]t c. 152,§ 1(4),and we have no 12. 0 Roof repairs employees.[no workers' comp.insurance required.] 13. 0 Other *Any applicant that checks box#1 must also fill out the section below showing tbij,7,_�,. ———————— policy information. indicating tbey,are doing all work then hire outside contractors mug submit a new affidavit indicating such. tHomeowners who submit this affidavit workers'compensation tContactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If trie subcontractors have employees they must ravidetheirworkert',camp,Miley number. am ran employer that is providing iw.w*ers I compeftyatton insurance for my employees. Beim is the policy and site information. InsuranceCompany Name: Traveters Ins. Policy#or Self-ins-Lic. 5 B 3 Expiration Date -7/21/13 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 of MGL 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for covers verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct: Date: PriniName: Normand Michaud Phonek 978 687 0544 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): I.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: -hone r, Rar 1, REGIS RED MASTER'ELECTI2ICIA 'ISSUES THE AS VC LICENSE TO: NORMAND D MICHAUD � 13 SIMPSON, RD INDHAM, U3087-2215 W, " NH � 15650 A 07/31/13 843727 `{ r n AS A REG JOURNEYMAN ELECTRIC! 6SSUES THE A50VE LICENSE TO: NORMAND D MICHAUD ' a 13 SIMPSON RD WINDHAM NH 03087-2215 34594 E 07/31/13 843726 11 IN r