HomeMy WebLinkAboutWire Permit - Permits #13111-1 - 28 CEDAR LANE 2/16/2014 g�\. \RIM
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North Andover, Mass.
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Fee
\ ELECTRICAL INSPECTOR EM\
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Commonwealth of Massachusetts Official Use Only
Permit Na.
F Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblarik)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00
(PLEASE PRINT IN INK OR TYTE ALL INFORMATION) Date: ;2-tC,- j 6
City or Town of. NORTH ANDOVER To the Aspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) a GA4_p-
Owner or Tenant :T6 52 Telephone No.
Owner's Address
Is this permit in conjunction witli a building permit? Yes No F1 (Check Appropriate Box)
2
Purpose of Building Utility Authorization No.
Existing Service Amps J Volts OverheadF] Undgrd El No.of Meters
New Service Amps Volts OverlicadF] Undgrd n 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 CeilSusp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above [j In- No-.-OTE mergency Lighting
grnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners IFIRE ALARMS No. of Zones
No. of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons..........JKW No.of Self-Contained
.................. Detection/Alerting Devices
Municipal El Other
No. of Dishwashers Sp ace/Area Heating KW Local❑D Connection
No.of Dryers Heating Appliances KW Security System
No.of Devices or Eq uivalent
No. of Water KW No.of No.of Data Wiring:
Beaters Signs Ballasts No.of Devices or Equivalent
Telecommunications Wiring:
No.Hydromassage Bathtub Total Up No.oMotoj�� No.of Devices or Equivalent
OTHER:
Att�ac additional detail i(destred,or as repdred by the Inspector of Wires.
Estimated Value of Medical ork: (When equired by municipal policy.)
Work to Start: Inspections to be requested accordance with NMC Rule 10,and upon completion.
permit
INSURANCE ,,,,.,.GE TTV or,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 El BOND F1 OTHER Ej (Specify.)
1cerqy, under thepainsandp, Of* pfperjurythattheinformation on this 1. ation is true and complete.
, les le le -3�,� C(, (- LTC.NO.: I
FIRMNAME- ,j 4�6A
Licensee: Al 9ea5"4�,) Signature LIC.NO.:
(If applicable,enter "exempt"in the license number line.)
Bus.Tel.No.-- CIS
/A 0) Alt.Tel.No.:
Address: j 1 4/41-41 41j I I? I k�oia LJ "I,
*Per M.G.L,c. 147,&57-61,security work requires Dep4Went 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 [I owner's agent.
Owner/Agent
Signature Telephone No. $
yhe Commonwealth ofmassq�ehuselts
Department of IndustrialAccidents
I Congress Street,Suite 100
-soston,AM 02,114-20-17
ipwminassgovIdla
Wor:kergq Compensation Insurance AfrldaAt:
To BE R")D WITH TWO,RERMTEENG AUTff OPJTY-
A Please print Legibly
Information Infomfl
IJ
AddreSs I C
Phot.io '7g,.L
Are-you an employer?check the appropriate box; Type of project.(p�qwred):
I-E] , . ,' employees(full and/or park tfina),* 'T. El Now consfMotiolL 2.JA f am no craployces worl&g forma In'a sole proprietor or partnership and 8- E!
capacity.LNowokors, insurance requirorequired,;]any9. El Demolition
3,,E]I am a homea7mar doing allworkurysr1f,[No,workers'comp.insurancalequired.]t 10 E]Buil.4ing addition
4.[:]lam a homeowner and will be hiring Contractors to conduct all work on my property. Ivill 11. Electrical repairs or additions
ensure,that all contractors either have workers,compensation insurance or are Sole
5.F]I am a general contractor and I have hixedtho sub-cpirtractors listed on the attached sheet. 13.E]Roofiepairs
These sub-co.ntractoi,qiiavepmPI employees and -workers'comb. asuran=�
. 9T d L14- OOther6.[]We area corporation and its offi9qrs have exercised their right of'exemption per MGf,G. El
152,§1(4),_d V?a—hava ,�MO
no.' `�I�Y p.V6worl(arsl comp.insurance required.]
*Any applicant that checks'bol 41 m;u,t also fill out the section below showing their workers'compensation policy ffifbnnatlon-
f big affidavit indicating they are doing all work andthea hire outside contractors must submit anew affidavit indicating such.
-Homeowners Who stbliiif k! - those antities have
Tcontrattols that"13.0ok thiq box.must-attached an additional sheet showing the natue,of the sub-contractors and statowhather or ncl�
&y'iaust provide their workcis'cornP-policy M1mb0r-
employces. I-Cthesub-c6i�traol6rgEa��OMPIDYces,
y Mv16Yee *BeJoV is t1lepolicy andjo-b site
jaman eftiployertliatispidvidihg-workerS"comquensallon insurance ftrai Q Mr
information.
policy 9 or Self-ins,Mo. ExplratioriDato:—
r Cit�/,State/Zip: AA, d� L
L
fob Situ Addros G olicy declaration page(showingthe Policy number and expiratlo e)-
Attach a copy of the work6rs'cbMp4tsat1(M P $1,500.00
Fathno to secure coverage as required under MCTL o. 152,§25A is a oximinal violation punishable by a fine up to
and/or one-year imprisoma unt,as well as civil penalties in tho form.ofa STOP WORK ORDER and a fine of up to$250.0 0 a
be fbiwarded to the Offico,of Tuvestigations ofthe DfA for insurance
day against the violator.A copy of This statement may
coverage verification.
undertl,.re aMs and penaft1e,9afpejYP,?.11 treat tjae infozrrttrtzon s ovzcled alaave ts true and correct
Date:
Si nature:
hone# 3
0 al rise only. Do not-write in thly area,to be completed by city or town of_flcial.
PermitfUce-Use
City or Town:
IssuingAuthoritY(circle One):
1.Board of Ifealth 2.Building Department 3.CityjTown Clerlt 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person'.-- phone B:—
By the Division of Professional Licensure
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Licensing Board:! ELECTRICIANS
License Type: JOURNEYMAN ELECTRICIAN
TYPE CLASS: E
License Number:? 37258
Status:', CURRENT
Expiration Date: 7/31/2016
s
2 Issue Date:: 9/12/1994
Exam Date: 8/6/1994
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❑
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c. 143,§3L.
Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application,
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012.
• Rule 8—Permit/Date Closed: Note:Reapply for new permit 0
•Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed Re-Inspection Required 0
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required El
Inspectors Comments:
Inspectors Signature- Date:
PARTIAL ROUGH INSPECTION:
Pass n? Failed Re-Inspection Required El
Inspectors Comments:
Inspectors Signature: Date:
ROUGH ENSPECTION:
Pass 0 Failed Re-Inspection Required 0
Inspectors Comments:
Inspectors-Si�gnatur�e.- ����
,et, Date: 0 -16 - 16
FINAL INSPECTION:
Pass Failed M
Re-Inspection Required($.) 0
Inspectors Comments:
Inspectors Signature: Date:
DEBWEfNHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com