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HomeMy WebLinkAboutWire Permit - Permits #13030-1 - 17 CABOT ROAD 1/14/2016 I `\ 10-7 Date......�...................................... 1101-0 IN IWO ©R�N NORTHOEM TOWN OF V ag RM r a• oe E, 0 sm PERMIT FOR WIRING 10 MM S�►CHUROME § � em ......... ............ " This certifies that ........e.......:. ................... ... .... ..... . . ..a............. s P ...................a•..... MGM, has permission to perform ,_� ........................ �\ on i ng of ..... _..a a. ...... .......a.._.....a....a.......,..............a.a......, wiring in the h€�ild ..... North Andover, Mass. ` ------------- at :._.. _ � A� ...a......... ... MOM- IN IBM ,� Lic. Imo: \ ... .....a. .. ......... ........ ...........1 ISO IN Fee ....... _.:.a ..,. _.�. .__a_ — ELECTRICAL INSPECTORMEN Check# } HE \\ \\ \ : __ _ IN C,,eImmonwealfia al f�aMacte,u;olb Official Use Only Permit No. 2eparLraxted ol�e"re _�eawiea� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev. 1lO7� (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts I',lectrical Code(MFC),527 C'Mlt 12.00 (I)LT,A,5"fit PRINT �1 or T IN INK Town o�OR I f 1 L' LL INf"4)fZ�C,*9T'1� I�t��"� To y pectior f Wires: . By this application the undersigned gives notice of his or her intention to perform the electrical wort.described below. Location(Street& Number) r 4" 12 6 Owner or Tenant Telephone No. OffLwner's Address t -7 7 - ;F f ` ' `' YesNo❑ ❑ (Check Appropriate Box) ... Is this permit in conjunction with a building permit Purpose of Building ' 1CJfp1C Utility Author No.of Meters Authorization No �mm Existing Service Amps / Volts Overhead ❑ g ❑ C p ❑ g E _ . New Set-vice Amps / Volts C)verhead Und rd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Y"C' Com Pletion o 'the vllowin,table rnar be ivaived by the Ins eetor of'Wires, No of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Na.of Total Transformers I%VA No.of Luminaire Outlets No.of Hot Tubs Generators KVAAbove No.of ... No.of Luminaires Swimming Pool d I rntl. ❑ Batter J Units envy rg rug 'µ No.of Receptacle Outlets No.at O1 Burners ) FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Cgas Burners Total initiating Devices 5. No.of Ranges No.of Air Cond. 'tans No.of Alerting Devices Heat Pam Number Tr>ns KW No,of Self-Contained " No.of Waste Disposers Totals: Detection/Alerting Devices Mutt' No.of Dishwashers Space/Area Ileating IOW Local ElMutt'cipal ct%on El Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.hlydromassage Bathtubs No.of Motors Total It Telecommunications Wiring: No.of Devices ar E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector Q/li Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: p Inspections to be requested in accordance with MBC Rule 10,and upon completion. INSURANCE COVEL AC;E: 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. Tile undersigned certifies that such ec rage is in force and has exhibited proof of same to the permit issuing office. CHECK:ONE: INSURANCE 9L-BOND ❑ OTIIEIi ❑ (Specify:) 1 certi&,under the pains and penalties of perparr",that the hif winadon aaa d as application is true and complete ;t FIRM NAME: & G` ��. LIC`. NC).: E ,,,c Licensee: Signature tie " LIC.NO.: (I/'applicable, enter " empt"in the lice ns rzernber i e.) Bus.Tel.No.: Address:M.G.L. c. l 57 � Vel" CJ Alt.Tel No.: * 7 s -61,security work requires Department of Public Safety"S" license: Lie.No. OWNER'S INSURANCE WAIVER: I aura 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 ❑owner's agent. Owner/Agent F� Signature Telephone No. �. $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 WWW.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgaiiizatiori/individual): Address: City/State/Zip, &7t Phone#: Are you an employer?Check the appropriate box: Type of project(required): I.U I am a employer with 4. 0 1 am a general contractor and 1 6. E]New construction J mployces(full and/or part-time).* have hired the sub-contractors 2 7. am a sole proprietor or partner- listed on the attached sheet. T 0 Remodeling Arship and have no employees These sub-contractors have 8. U Demolition working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition [No workers'comp. insurance 5. R We are a corporation and its ]0. Electrical repairs or additions required.] officers have exercised their 1 U I am a homeowner doing all work right of exemption per MGL, I I Lj Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.[:] Roof repairs insurance required.]t employees. INo workers' 13.01 Other comp. insurance required.] L--------------- __...........- *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. '*Contractors that check this box must attached an additional sheet showing the name ol'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. Lie. 4: Expiration Date: Job Site Address: 17 r- Y A City/State/Zip; 1, -(e6 116K Pent - ------ 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, fdohereblycertifyun �rthepainsandpenaftie of perjury that the information provided above is true and correct. 11 f jmy er Signature., Date: Phone#: Official use only. Do not write in this area,to be completed by city or town a Iciat 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 H;