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Home My WebLink AboutWire Permit - Permits #12420 - 120 CAMPION ROAD 6/5/2014 tii �\ INS #00 Ogg 1011 '- £;.,. 111 \\ \ ma g NDOVER NORTH A ,. TOWN OF a NOR o I IN- E `\ fiv \ a K� iir \ 01 BThis certifies t tt`:...... . . ...... .� o E fi \ \ ef � Sror111 _....... ... .... �. .. .. soon p \\ VIN �° wiring an the bu�Iding of .:. \\\ IM o ` NorthAndover, Mass \\ :. . at .. :.. INE 04_ s V` :.... Lic. No.. .......... rx c aMIN INSPECTOR �� ka Check fi SOY a = s ` Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.im] (leave ................ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod 7 CMR 2.00 (PLEASE PRINT IN INK OR TYPE ALL EVFORM,4 TION) Date: r7'l�,- 14 City or Town of. NORTH ANDOVER To the Inspector ofWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant ,tr 0"Tt f,�>) C Telephone No. Owner's Address "J Is this permit in conjunction with a building permit? Yes [SK No F1 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead [I Undgrd 0 No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 9� Con;pletion of the followin table may be waived by the lnspector 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 lNo.of Luminaires Swimming Pool Above o In- N—o.76YEmergency Lighting grnd. grnd. F1 Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo. 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 KW No.of Self-Contained Totals: - Detection/Alerting Devices Municip F1 No.of Dishwashers Space/Area Heating KW Local El Connectiopin other No.of Dryers Heating Appliances KW Security Systems:" No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts , No of Devices or Equivalent. dromassage Bathtubs No.of Motors Total lip No.of Devices or Equivalent No.Hy lecommunications Wiring: H T OTHEe LR.:: 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 coveSAge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Pf❑BOND 0 OTHER n (Specify:) I certify, under the a penury,that the information on this application is true and complete. FIRM NAME,M and of LIC.NO. Licensee: Signat LIC.NO.: (1fapplicabl ent r "exe t"in the license tuberBus.Tel.No.-W- Address: AltH03814 Alt. •Tel.No.: 1A ?i *Per M.G.L c. 147,s.57--61,security'—work requires Department of Pugli`C-Safety"S"License: Lie.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. lam the(check one)Downer F1 owner's agent. Owner/Agent Signature Telephone No. FEE.-$ The Commonwealth of Massachusetts Department of Industrial Acci6nits Office of Investigations 600 Washington Street Boston,MA 02111 wwwmass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information- Please Print Legibly .* Name (Business/Organization/Individual): F-L -4- ki �,&rxt,) Address._,+4 M Eck LV City/State/Zip: 11 �0n & i ft 038A(Phone !T ?E- V7 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. D I am a general contractor and 1 6, 0 New construction mployees(fall and/or part-time).* have hired the sub-contractors 2.ET-10 am a solo proprietor or partner- listed on the attached sheet. 7. rl Remodeling ship and'have no employees These sub-contractors have S. El Demolition working for me in any capacity. workers' comp.insurance. 9 [No workers' comp.insurance 5. El We are a corporation and its . D Building addition required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance required.]t employees.[No workers' 13.F1 other comp.insurance required.] *Any applicant that checks box41 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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.9: Expiration Date: U Job Site Address: 2 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or oner-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer under the pal andpenahles of zerjury that the information provided above is true and correct. Signature: Date: (p Vhone#: Official use only. Do not write in this area,to be completed by c4 or town official. City or Town: Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:- Phone#: UNWEALTH O,,F IMASSA ,-HU SETT$: � E,LVVI'M I C �iNS G « ,x ,ISSUES THE-�FOLLpWIh1,C -kICENSE ` A5; {� .REG JOURNEYMAN .fLECTR IBC I a ` ' tOR.A W1 NSLOW MBERW00D ,T>�In�so� rr�t; 038� �-2zo's 35�9�+ E �7/311a� 47955 ❑ 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 rm or corporation stated on the permit application. Such entity shall be responsible for the electrical permit shall be issued to the person, fi 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. El Rule 8—Permit/Date Closed: Note:Reapply for new permit 0 0 Permit Extension Act—Permit/Date Closed: Trench Ins action Pass M Failed 0 Re-Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required El Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re-Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: ROUGH INS 10N: Pass Failed 0 Re-Inspection Required El Inspectors Comments: /X Inspectors Signature: //-I,-"VIA, Date: 7 /I FINAL INSPECTION: Pass[N Failed Re-Inspection Required 0 Inspectors Comments: Inspectors Signature: Date; DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofmerrimac.com