The URL can be used to link to this page

Home My WebLink AboutWire Permit - Permits #12956-1 - 10 CAMPBELL ROAD 12/14/2015.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 11101 Date ............. .. IN WIN AN OF O \ \ \\ ATE \Rl `\¢. . NER phis crtifie thatINN . . c ,o\ er °ssioll ass \O a the c ...,,,.<.< . ................North� Ove hii � Agg w lu . W �. 10, ph \ ,.... .. ................ � �\. . Al- at _ .. A ..,.. ffA Lic fee .. .. �\\\\\\ - S, \\ \� INER ffill wo , Official Use Only Commonwealth of Massachusetts Permit No. Department of Fire Services Perm Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WQ,527 CMR 12.00 1 (P1,E1,4SE PRINT 1NJATK OR TYPE ALL MFORM Y10N) Date: 10 1. 1 //i City or Town of. NORTH ANDOVER 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 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes El No J5�� (Check Appropriate Box) Purpose of Building is Utility Authorization No. -�-U`7 9'2,7/�' Existing Service Amps Volts Overhead � Undgrd❑ No.of Meters New Service Amps Zc,, Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 12qlac /�a 4yelt. �0 C- 6, ,, -r ,� ry 14 1 1 Completion of the followin table may be waived�y the Inspector of Wires, ty the:i1spic:�:or:C No.of No.of Recessed Luminaires No.of Cefl.-Susp.(Paddle)Fans Trans Total formers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above n In ❑ o.0 Emergency Lig ting grnd. grnd. 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 Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices ............. No. of Waste Disposers Heat Pump Number I Tons IKW No.of Self-Contained Totals: I Detection/Alerting Devices P F1 Other c No.of Dishwashers Space/Area Heating KW LocalElMunic' �'Connection 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.. No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:No.of Devices or Eauivalent [OTHER: Estimated Value of El t ' I Work: Attach additional detail if desired,or as required by the Inspector of Wires. pc rica (When required by municipal policy.) Work toStart: /2a`r 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] OTHER El (Specify.) Icerfif and ofperjury,that information on this application is true and complete. y, under the P FIRM NAME: d L_1 LIC.NO. �12 2—�3— Licensee: Signature LIC.NO.: (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.---212--43- Address: 21j-e <, / C'4-c, 4. o L22 Alt,Tel.No.: *Per M.G.L c. 147,s,5Y-61,security work requires Department of Public 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,f hereby waive this requirement. I am the(check one)[I owner D owrioi-I agent Owner/Agent Signature Telephone No. PERMIT FEE.- $ The Commonwealth of Massachusetts F Department of IndustrialAccidents a 1 Congress Street, Suite 100 Boston,MA 02114-2017 $w,sW www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Marne (Business/Organizationflndividual): J0 4 1 . —e i ce.t e 71 r f �- Address: 7 Ocp,7 e City/State/Zip:_ c,.*e -3 Phone Are you an employer?Check the appropriate box: Type of project-(required): 1.L_l l am.a.employer with employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions S. I l contractor I have hired the sub-contractors listed on the attached sheet. ❑ am a genera racor an 13.n Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. d 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.Lie.#: Expiration Date: ,�� / � Job Site Address: !o l " _City/State/Zip: / -141, Attach a copy of the workers' campen ation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.,," X do hereby certif and r tl e a and penalties of per;jury that the information provided above zs rue and correct. Signature: Date: 2--, ° Phone#: z J'Y—k3 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 Contact Person: Phone#: Commonwealth of Ma usetts Division of Fiegistrali Board ofElectr i JOHN J " 10 SUM - SALEM, A Master Elec a 21725-A 07/31/2016 008832 License No. Expiration Date. Serial No. k