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Home My WebLink AboutWire Permit - Permits #13119 - 315 CANDLESTICK ROAD 2/23/2015 SUP \\. - ....... ...:.3...... \\� \\ Date h \ � NDOVER \ NORTH A n*-n IAN ZING FOR VVIF IISOM IN M, VMS I MM \` \\W\ .................. .. --B VA .. %p �A mi This certifies thatSwim- ..... =. 101 EMB v a o = .... \� �\.. I \`nto e o ........ �has e ssi fi......... �n in the building h Andc�e�, Mass- IBM ili ME ......, \ MI at - ic. Igo. �.... . � .. ... ��c RICA�I�se�erc�x ~` Fee.... . . ... . ..... L 1 \ �IIS \� Check Im F, .. IMME Commonwealth of Massachusetts Offigial Use Only 1,5 Department of Fire Services Pennit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. i/rl (leavebla*) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C?,defWg-527 CMR 12.00 (PLEASE PRINT INJAW OR TYPE ALL INFORMATION) Date: T City or Town of. NORTH ANDOVEi R 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). 3 Owner or "Tenant Telephone No.'I&Oi-o Owner's Address 1c Is this permit in conjunction with a building permit? Yes F1 No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd[I No.of Meters New Service — Amps Volts OverbeadF] UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingtable 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 Luminaire Outlets No.of Hot Tubs Generators KVA Above In n No—.—OTE mergency Lighting No.of Luminaires Swimming pool Rrnd. grnd. Batter v Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS IN' o. of Zones of Detection and No.of Switches No.of G29 Burners No. Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons heat Pump I Number I Tons 1KW No.of Self-Contained No. of Waste Disposers Totals: ...............I I........................................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local E] Municipal D Other Connection No.of Dryers Heating Appliances KW Security Stems:* No.of Devices or Equivalent o. of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wares. Estimated Value o[Elec ical Work: LA 1;6 (When required by municipal policy.) Work toStart: :2 10 t1-:) —Inspections to be requested in accordance with NIEC 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 sur,4-coverage is in force,and has exhibited proof of same to the permit issuing office. I CHECK ONE: INSURANCE N BOND 171 OTHER F] (Specify) I certify, under thepains and penalties ofperjury,that the inforination on this application is true and complete. FIRM NAME- LIC.NO.: Licensee: i-dvn 9N Signature LTC.NO.: ( 1-7 0 app licable, a ll enter "exempt" Bus.Tel.No.:(bY2 Address: Alt.Tel.No.: Per MG LC. 147'S.5 317 -11 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)[I owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth o,f'Massachusetts .D►epartment of lndustrigl.Aceldiints Office of-Investigations 6D0 Washing-ton Street Roston,MA 02111 UV www.mass govtclia Workers' Compensation Insurance Affidavit:BuRders/ContractorsMectritcxans/phi .bees Applicant Information Please kr inl Le zbl Name(Business/Organizationitdividual): Address: City/State/tip: Are you an employer?Check the appropriate box: Type of project(required): 1.C( 1 am a employer with 4- ❑ I am a general contractor and 1 6 ❑New construction. employees(M and/or part-time).* have hired the sub-contractors 2. 1 a a sale proprietor or partner- listed on the attached shoat, 7• remodeling m. ship and'laave no employees These sub-contractors have 8. Demolition woxldng forme in any capacity. workers'comp.insurance. 9. ❑Building addition. [Nb workers' comp.insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions required.] officers have exercised.their 3.❑ Z am a homeowner doing all work right of exemption per MGL 11.C(Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we,have no 12.Q Roofrepa rs insurancerequired.]; employees,[.l�lo workers' 1311 Other comp,insurance required.] YAny applicant that checks box must also fill out the section below showing their workers'compensatian policy information. -Homeowners who submit this affidavit indicatingthey 9 doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checktfus box must attached art additional sheet showing the name oftho sub-contractors and their workers'comp.policy information. .I'am are emyloyef that ispvavirling workers'compensation insuranee foamy ernplayees i3elow i�thepalicy a�zdloi'r site Nfarmation. Policy#k or S elf-ins.Lic. : c , _ Expiration,Date: �. Job Site Address: -pit /state/zip Attach a copy oldie workers'compensation-policy decla7ration.page(showing the policy number and expiration date). Failure to secure coverago as requiredundor Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER.and a fine ofup to$250.Q0 a day against the violator. Be advised that a copy of this statement maybe forwarded to the O.ffico of Investigations of the DSA.for insurance coverage verification. T do hereby eert urtrie�tr ins andpenaltles of e ' hat Me informationprovidedabove is Ire and correct, Date: Phone#/• Official use oply. -Vo not write in this area,to be completed by city or town official. City or Town: Permit/License 0 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 0: , a