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Home My WebLink AboutWire Permit - Permits #11678 - 271 CANDLESTICK ROAD 6/21/2013 IMUN EN \\ \` Date z \\ ........ ...... ......... Wili 10 #3TON Mi, TOWN OF NORTH ANDOVER IMILL Milli o _ \ \\\� _ NNEW` NUI gg \' i6 .\ W. \: W 1001, Th is certifies that _ \\ a ......... has permission to perform' .................... ................................................ Ufll � �\ wiring in the h1di� ._.... .. ...... ......... ..._.,................,, �� 01,11 \\\ \\ .......... at Andover, ..... ........ ::... ...... ...;;.._:..............,.... r, ass. �:. \ Fee. ic. . ......._ .......... No ......... ........... :... .. ... \Sn'\ \gp\ \ ' ELF CAL INSPECTOR CWE k FzBROKE �\ " \ N tl ,a e n Y Common wealth of Massachusetts Offic* I U 0 ly Permit NO. Department of Fire Services Occupancy and Fee Chocked BOARD OF FIRE PREVENTION REGULATIONS [Rev.I/o7j (leaveblaA) 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 INJAW OR TYPE ALL INFORAM TION) Date. 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) 0? 1 pc)cc/� Owner or Tenant !S(,C,1C,,1.C,1/0 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No [3'--(Check Appropriate Box) Purpose of Buildingh, s. Utility Authorization No. Existing Service?-04) Amps O'd 9 14Volts Overhead F1 Undgrd No.of Meters New Service Amps Volts Overhead El UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Inspector of Wires. No.o Total No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA r7 ,1 No.of Luminaires Swimming Pool Above n In- ❑ N-07-OTEmergency LigEting grnd. grnd. Battery nits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JN' 0. of Zones No. of Switches No.of Gns IB urners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices al Heat Pump Number I Tons I KW No.of Self-Contained No. of Waste Disposers Totals: ......................I........................F................. Detection/Alerting Devices Munic'PP' [:1 Other No. of Dishwashers Space/Area Heating KW Local El Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent o.Hydroma Total HP Telecommunications Wiring: No.of Devices or Enuivalent Xo_.of Water KWNa.of No.of Data Wiring: Heaters KW aters Signs Ballasts No.of Devices or Equivalent ssage Bathtubs No.of Motors rOTHER: I 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 cov,Qrage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE r] BOND El OTHER 0 (Specify:) I certify, under en alties ofperjury,that tree information on this application is true and fhe�a*ns and penalties complete. FIRM NAME: . I&) 2,11C�,1 0-t 0 LIC.NO.: /8 z 6 LTC.NO.: 7'60tj — -- -1 Licensee: �C� Signature L_ (Ifapplicable,dwer "exempt'in e license number line) Bus.Tel.No. '77F 36e Address: /15 e I�c/ vt vr J�a,4 , M,lkl 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)[I owner El owner's_.igq Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts .Department of lndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 Uto www.mass gov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narne(Business/Organizationllndividual): 6,11L ( e"'i1 J`_ /"_,J Address: C 5" �° ,Ae City/State/Zip: li to " ., d . 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 6. ❑New construction cm loyees(full and/or part-time).` have Hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7 ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. g. Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL M❑Plumbing repairs or additions myself. [No workers' camp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees. [No workers' 1311 Other comp.insurance required.] OAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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 for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: 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 of MGL 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 for insurance coverage verification. I do hereby certi y under thepains andpenalties ofperjury that the information provided above is true and correct. - Si ature: Date: 6 -21-1 Phone#: ! 4 � � Oil D 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): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: c y WEAL(H CE MASSACHUS 1 a s • a :e. • • ,E1ECT11AN i AS A`REG JOURNEYMAN ELECTPNI(AN 'ISSUES THE ABOVE LICENSE TO: -RYAN T TERRAZZ.ANG - i i r 6 , t=F'Mi I ANC? h1A 01 8.36 1 i i s + _.:•