Loading...
HomeMy WebLinkAboutWire Permit - Permits #12331 - 173 CAMPBELL ROAD 5/5/2014 ot Ell M E oDate .........g .......... O ...r� JL TOWN OF NORTH ANDOVER -m\ p PERMIT FOR WIRING \ ,t iftr- Ilin 0111 \ MEN' N NORM NO c IHAUJ MINE, In& \: ThiS certifies thatIn I 111001, . ... . � �\ \yid IN has pernussion to Perrin 110 Ag IN gom_ wiring in the bu ng cif, V .... ......... ................................................................ \\ \ at .. ......... ......... .... ._...._....................... ... North Andover, INS agi \ � --Fee _ S. Y �1C. _. a.. .>... IM .. ........... `gN Check# \\ gtgu \\ IM _ _ \ \\ Oflicial Use OnI Permit NO. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (leave blank) 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 TAT INK OR TYPE ALL INFORMATION) Date: City or Town of. (V4>,R7W 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) Owner or Tenant /7 3 &-a- eo_b Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadO UndgrdE1 No.of Meters New Service Amps Volts Overhead D UridgrdO No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .740-6,q Wf-77 Completion ql'the fig4owing le may be waived by the IS�ec�or a i o— f Mires. No.of No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total formers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above D In- 0.of Emergency Lighting No.of Luminaires Swimming Pool grnd. grad. Batte!1 Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JNo.of Zones No.of Switches No.of Gas Burners o.of Defe—etion and Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump I.N.p.mber I Tons W No.of Self-Contained No.of Waste Disposers Totals: ................ _JX.1­.11­­­1 Detection/Alerting Devices n Coicipal No.of Dishwashers Space/Area Heating KW Local Connection 0 Other No.of Dryers Heating Appliances KW Wurity Szs:tems:* No.of vices or Equivalent No.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 Equivant OTHER: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE n BOND F-1 OTHER. E] (Specify:) I certify,under the pains and penalties of perjury,that the information an "thisappli is true and complete. FIRM NAME: ELCL-TRICIAL- CON 7-R ACT-&-K-i LIC.NO.: Licensee:' r,>iA\t i C> 14,46&4P, Signature LIC.NO.: 0 (If applicable,enter"exempt"in the license number line.) r,� -1 E, �A, Bus.Tel.No. 71 la Address: P,­1 0 t__ L M 0 H 7- 6 7- N 0 06,4 i-�k Alt.Tel.No.:1111y' '%3PY­a) 5q *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 ❑owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. The Commonwealth of Massachusetts . ...... Department of Industrial Accidents _-Z Office of Investigations 4 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DAVID ELECTRICAL CONTRACTING LLC Address:87 BELMONT ST City/State/Zip: NORTH ANDOVER, MA 01845 Phone #:978-682-6262 Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with 8 employees (full and/ 5. ❑ Retail. or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] $ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** I I.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, ELECTRICAL CONTACTING with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also till out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy information. Insurance Company Name: FEDERATED MUTUAL INSURANCE CO Insurer's Address: PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy#or Self-ins. L.ic. # 9353694 Expiration Date: MARCH 1, 2015 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 in ce coverage verification. I do hereby certify, under t pa n ties of perjury that the information provided above is true and correct. Si nature: Date: 5�Zt6i l Phone#: Z 2-,�C 2— 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.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia r - F3s.,�i�c� — ! e� c �s � � - c '1 � � � � �'`--.�3� :5 I � gp `� � 1 k � �# � � :: i � �� � � � � � '' �� - �! ��, �' �� �.. �� �� � � � ' �:�3 ��r, � � M� �`� =�_�- x �= v - _ �, -� w �w 1 ..,._ 1. ,� �- �.