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Home My WebLink AboutWire Permit - Permits #12827-1 - 205 CAMPBELL ROAD 11/3/2015\\ � \\ r _ \ DateIm o ; NO \\ \\ AM OO T#f TOWN OF NORTH ANDOVER `\ •' Z. �� ' 0 ICIWIRING � O ` =• a gm gm Am 100 INS ISM All \\ This certifies that ............................ .. .... m has permission Prf Illm ................................ ggii wiring the huil in f _ INS, I�1c�r nQ�cr; ass. INNER at �. ........ .` .... � c \ _ SPECTOR.....,...... Lic. No. Em E� Fee ., ,_ _ ELECTRICAL IN �� NS CheckRN gim ON m- IN 4 ISS \\\ Commonwealth of Massachusetts official use Only Department qfFire Services permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked V (Rev. 11/991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MF 27 2.00 TYPE (PLEASE PRINT IN INK OR TYPE L FO MATION) Date: City )r Town of of 9ye k.,,e/,N To the Ins ector of Xires: her- By this application the undersigns egive�lnofice of his o7 intention to perform he electrical work described below. Location(Street&Number) Owner or Tenant 14 q V Tel-phone No. Owner's Address � 060.11wt- Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box.) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead Undgrd ❑ No. of Meters New Service Volts — Amps Overhead❑ Undgrd ❑ No. of Meters Numberof Feeders and Ampacity Location and Nature of Proposed Electrical Work: coin !etion of fotlowin table maybe waived by the inspector of wires No. of Recessed Fixtures No. of Ceil-Susp. (Paddle)Fans �rodnos'formers Recessed N 0 ' 'S�c s ------ No.of Lighting Outlets No. of Hot Tubs Generators KVA Fixtures t Swimming I Is n- o.o :�rn gency 1.1griting No. of Lighting Fixtures Swimming pool 10 KWe F-1 , _Battery'Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo.of Zones -95�-01 etgction alld Na. of Gas Burners Initiating No. of Switches Mating Devices Tutaf— No. of Ranges No.of Air Cond. Tons No. of Alerting Devices Meat P p INum er W - No. or Selt-"ittained No,of Waste Disposers otals: I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW local El municipal El Other Security Systems No. of Dry ers Heating Appliances KW No. of Devices or Eouivalent -No. of ter NO. OT Data wiring: W14caters KW Signs No. of Devices or Equivalent No. Hydro massage Bathtubs No. of Motors Total IIP, I eFecorrimuni-cati-on -ri n g: No. of Devices or Equivalent OTHER: or..Eauimalent A much additional detail if desired,or as required by the Inspector qf*Wires. INSURANCE COVERAGE:Unless waived by the owner, no permit for the performance of electrical work may issue unless tile licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. Tile undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [-] BOND [] OTHER [:] (Specify.-) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion i,certify,under the pains and penalties qfperjuty, that the information on this application is true and complete FIRM NAME: Deveau Electric LIC. NO 11380A 1-icensee: James N Deveau LIC,NO 11380A if plicablefpt I 'Ly t i 64cese rumter Bus. el.No.978-388-9662 Adyrss: oxj AMeS y, Ma. 01913 Alt-Tel. No.979:38T- 6 OWNERS INSURANCE , : am aware that the rice—n,,ei.-7To-e-s-not- av—e Tie-ri`aii`iity insurance coverage normally required by law. By my signature below. I hereby waive this requirement I am the(check one)-O ownerF1 owner's agent Owner/Agent ' No...... PERMIT FEE. $ Signature Telephone -F The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders / Contractors / Electricians / Plumbers Applicant Information. Please Print Legibly Name(Business/Organization/Individual)* DEVEAU ELECTRIC Address-. P.O. BOX 1024 ---_--_-- ----_.---- City/State/Zip AMESBURY, MA. 01913 _ Phone # 978-388-9662 Are you an employer? Check the appropriate box: Type of project (required): 1.JZ I maemployerf with Four 4. ❑ I am a general contractor and 1: 6. ❑ New construction employees ( or part-time).* have hired the sub-contractors 2.❑ I 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. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp insurance required.] 5. ❑ We are a corporation and its l0lectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their H.❑Plumbing repairs or additions myself[No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, 5w' 1(4), and we have no employees. [No workers' 10".❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. t Contractors that check this box must attached an additional sleet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,the must provide their worker's comp.policy number. I am an employer that is providing workers'compensation insurance.fiar my employees. Below is the policy and job site information. Insurance Company Name: Merchants Insurance Company Policy # or Self-ins. Lie. #- WCA9095009 Expiration Date: 12 / 12 / 2015 fah Site Address: Q2 DS�G'��... �� /L' �+ "---City/State/Z,ip: W-? 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 certify under the pains and penalties a . erjury that the information provided above is true and correct. Signature". Date: '°` �!�_ Phone - 978-388-9662 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other CDN1t 9E/�►B�1° ,+I IF +r HUSE 1 EI: TR I C I AN5 �,SEIES �'4 E'.'OLLOWI NG 1 I CENSE AS A � E I CERED AS f.ER ALE@ I?I C A EVEAU ELECTRIC ., ME ' A9 DEiIEAU §z s y 2` I iENAL� R J 0021�� $ °1 �t WkA 019,13 E f t