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Home My WebLink AboutWire Permit - Permits #12324 - 60 EDGELAWN AVENUE 3 4/29/2014 g 01011 ISM- 4 10107 Date.. rtOR41111.11.11 1-10 TOWN OF NORTH ANDOVER rh \ OF !@ \ AM * -N WIRINGFOR ME 101 111071-11 ..a` t� HU MOM M. is certifies that .................. ........ ......... ........_ v gg has permission nss�on to perform ..... ........ _......... \\ `y\\\ wiring in the building o ... ...:..a.. ... at ,. \ \\ - ........ ......................................................... cave s fl North Andover, bass. INS 37 s ,\ 11000 Fee.............................. NOT 7x :.ALE CAL INSPECrOR Check#IMMUNE - i .z MISS 17 `\ ly Commonwealth of Massachusetts Official Use qO -4. 1 Permit No. 3A Department of Fire Services 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(MEC),527 CMR 12.00 (PLEA SE PR TNT IN INK OR TYPE-4 L L INFOR MA TION) Date: J12�11;L� City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to per o the lectdcal work described below. 62CLocation(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permi . Yes No F] (Check Appropriate Box) C�� Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd D No.of Meters New Service Amps Volts Overhead n UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the fallowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil,Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above o In No—.-o-f Imergency LigEt—ing grnd. grnd. Battery Units No. of Receptacle Outlets No.of Oil Burners IFIRE ALARMS I No. 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 I Number I Tons IKW No.of Self-Contained .............. . ............Number ......................I.......................Totals: Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local 0 El 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." Telecommunications Wiring: No.Bathtubs No.of Total HP No. f Devices or Equivalent— OTHER: Estimated Value of Electrical Work: 3 Attach additional detail if desired,or as required by the Inspector of Wires. �X'3 — (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NMC 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. CHECELONE: INSURANCE BOND M OTHER F] (Specify:) I certify,under the gins an pena les ofperjuiy,that the information on this application is true and comp lete. FIRM NAME: VUL LIC.NO.: Q, I Licensee- - Signature LIC.NO.: 3`71-5L (If applicable enterd" 1 3 in the licq e numb xept" ,�inel Bus.Tel.No.: 1, Address: AIt.Tel.No.:&xA3 *Per M.G.Lc. 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)[I owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth ofMassachusetts Department of IndustriglAccidents 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/OrganizadorAndividual): D --L Occf r - Address: CA V&'` �� City/Stale/Zip• f" `' Cg f Phone#: & 3- -Z&` 7L 1 Z ,Are you an employer?Check the appropriate box: Type of project(required) 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).` have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet.t I emodeling ship and'have no employees 'These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 9. ❑El Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself.[No workers'camp. c. 152,§1(4),and we have no 12•n Roofrepairs insurance required.]t employees.[No workers' 1311 Other comp.insurance required.] `Any applicant that checks box41 must also fill out the section below showing their workers'compensation policy information. Al Homeownerswho submit this affidavit indicating they 6're doing all wont and then hire outside contractors must submit a new affidavit indicating such. lContraetors that eheekthis box must attached an additional sheet showing the name of the sub-contraotors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the poldey and job site information. Insurance Company Name:. Policy#or Self ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Aftach.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 maybe forwarded to the Office of Investigations of the DU for insurance coverage verification. I do hereby certl&under the ins andpenalties ofperjury that the information provided above is true and correct. Date Simature: �&, ----- Phone# ) Dfficdal 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#: 0 4 m , S5UES THE FOLLCIWI N . tL;I ,`WS'i AS. R �iE JaItRNEY,MN EL ECTR I C I AN fnt EVEN :E PiAt1 PS �; w tJ, 1 GLYEI`E5 DALE k ANUI LL"E Nli. 03$19-325o i 37i °8 E7J3o��a�7, �-