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HomeMy WebLinkAboutWire Permit - Permits #12196 - 240 CHARLES STREET 2/27/2014 INS INN DateON ..... _....... 10 \' iq SEE! an TOWN OF NORTHE E� PERMIT F WIRING o * �. O gq'g ISM All � \ Nw -` s certifies at \\ go has permission to perform .... ......... .. ......................... .......,ti wiring in the buzz ...................:aa .. \\ at ..... . ....... . � orth Andover, Mass. . ....... o \ Fee .... ............. Lic. No. . . . .�; ow SEEN act SPECTORillNUILLUNI'l \\ Check \'ne _ Z4 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 12,1 BOARD OF FIRE PREVENTION REGULATIONS Permit Fee Assigned u,p [Rev. 11/99] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK FOR INSTITUTIONAL* USE ONLY This form is for use by institutions employing licensed electricians and others for which notice of electrical installations to the municipal Inspector of Wires is required for work on the premises of the institution. If you are not an employing institution pursuant to C. 141 §8 of the Massachusetts General Laws,stop here. You cannot use this fp rm. Use the standard form only. (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NbC 66kbVe_,( To the Inspector of Wires: By this application the undersigned gives notice of the on-premises performance of electrical work by employees. Institution GK'ek-t-Ci- �---xjTsr�c-e, Address— Location and Nature of Proposed Electrical Work: 'S C,�A e— It Q cKivit-A0,4 CQ NOTE: C. 143 §3L of the Massachusetts General Laws obliges those who perform electrical installations to give notice of same to the municipal Inspector of Wires. You may do so by filing this form upon each such occasion, or if so contem- plated in an annual permit fee schedule set by the municipality you may maintain a contemporaneous log of such work, which shall be exhibited to the Inspector of Wires during normal business hours without advance notice. Some municipali- ties may set nominal fees for annual permits and require individual permits for work above a stated magnitude. We will file this form on each such occasion(check one): YES F-1 NO PQ We will maintain one or more contemporaneous log(s) (check one): YES NO n This option is available where so contemplated by the municipality. In these cases,you must renew this application annually, and upon significant changes in employment. The following individual(s)will be responsible for the accuracy of the log(s),if maintained. You agree that the log(s)will be located as indicated below. The coverage in any individual log must be for contiguous property except by arrangement with the Inspector of Wires. Attach supplementary sheets if required for additional log locations. Log coves ae,and location where it will be maintained Responsible person tic You may maintain the logs electronically upon agreement with the Inspector of Wires. If you intend to apply for such a proce- dure,indicate below how the Inspector of Wires should access the log: How many electricians and/or system technicians(as licensed by the Board.of State Examiners of Electricians)do you employ at your facility? Indicate the total number and also indicate the number of full-time equivalent staff that number includes: Total electrical employment: 3 Full-time equivalent electrical employment: How many helpers or apprentices do you employ to assist your licensed staff,wider their direct supervision(see c. 141 §8)? In general,this number must not exceed the ratio of one licensed individual to one unlicensed individual. Limited exceptions ap- ply for veterans(see St. 1962,c. 582 §3 as amended by St. 1979,c, 156). Indicate the total number and also indicate the num- ber of full-time equivalent staff that number includes: Total electrical employment- 0 Full-time equivalent electrical employment: Not all electrical work for which notice to the Inspector of Wires is required must be performed by licensed personnel. How many such persons,not required to be licensed,do you have in your employ? Indicate the total number and also indicate the number of full-time equivalent staff that number includes: 711_1 Total electrical employment: k_-) Full-time equivalent electrical employment: *Institutions are defined for these purposes as any person,firm, or corporation operating under c. 141§8. (Please see reverse side for certifications and required signature.) institutional Permit Form,page NOTE: Some institutions enter into contracts with contractors to perform Ongoing electrical work at an institution, similar to institutional employees, if,by the terms of such a contract,you direct the performance of such work,include the num- bers of such employees in this application. If the contractor directs such performance, of if the contract period is for less than one year, application must be made by the contractor on the standard form for such work. Do not include such em- ployees in this application. . In addition, Please give your official title, such as"Director of the Physical Plant" or"Director of Facilities" or equivalent provide a statement that substantiates your authority to hire electricians pursuant to c. 141 §8 for electrical work on the premis- es of your institution, and to establish priorities for the performance thereof. This form is not to be construed as a grant of au- thority to direct any licensee of the Board of State Examiners of Electricians to perform work in contravention of the rules of said Board,or in contravention of the Massachusetts ElectricaC l Code. 1/1\ My title is: te o'\C1 Ljz, - e ) � r,�'� _ 'k My authority to act for the aforementioned institution is: %(? kC 1 C(0.11 KC e, St I certtf lete. Y,under the pains andpe nalties of perjury,that the information oil this appileadoil is true and collip (Signature) (Dated) (Print name) D 0 \C kz,0 (work telephone number) (extension) (facsimile number)