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Home My WebLink AboutWire Permit - Permits #12223 - 77 EDGELAWN AVENUE 12 3/13/2014\� l z fil 21 ` - \ 12 \ _ \\ _ � KENN \\ • 4e *' \\ \ IM IBM gg 1 PERMIT FOR WIRINGMl .. .. O ° HU IN -_- WER IN WN \\ T21S certifies that , ... ................. ....... ....... ....... ........................... 0� \� Effi has permission to perform ...................... w ..._ Am Ng 11 IM- n intieuIdn of.....:................: � \\10, �\ ... ................. ........ ..... rt Andover, Mass. OIEN lEI ; = — 4 � _ -a � Mv 2CO� ....._.. .... �. ,. _. ...... .. .... ........ ._....... � ELECMCAL INSPECTOR �\\ \\ 001 Check = f x \\ ems= \ - NNER \ Commonwealth of Massachusetts Official Use Only o Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o7] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CNIR 12.00 (PLEASE PNNTINIKK OR TYPE ALL INFORM,4TIOA9 Date: /617z/-s 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 Mo r I e C-,,, 4 Telephone No. Owner's Address Qu re�3o\ Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building I Utility Authorization No. Existing Service Amps Volts Overhead❑ UndgrdF] No.of Meters New Service Amps Volts Overhead[-1 UndgrdF] No.of Meters Number of Feeders and Ampacity Location a�Natureo�Proposed Electrical Work: dO OA,elO'd re—C-60eCt9h.'"NV CO3,F&-J qna 6htnc;er�= Completion of the followingtable may be waived by the Inspector of Wires. No. - No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Tr o Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above o In- ❑ 0.0 iuergency Lighting grnd. grnd. Batter y Units No. of Receptacle Outlets No.of Oil Burners 1FIRE ALARMS No. of Zones No.of Switches e2 No. of Gas Burners No. of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No. of Alerting Devices Tons Heat Pump Number I Tons I KW No.of Self-Contained No.of Waste Disposers Totals: ........................I—........... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mun1c'pPl El El Other Connection No.of Dryers Heating Appliances IcySecurity Systems:*No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent__ Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP NO.of Devices or Equivalent OTHER: Attach additional detail ifdesired or as required by the Inspector of Wires. Estimated Value of Electrical Work- C> (When required by municipal policy.) -- - A6 Work to Start: Inspedidifs 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 Cov3wge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [0 BOND 0 OTHER F1 (Specify:) J certify, under penalties q perjury,that the information on this application is true and complete.the and FIRM NAME: k- � LIC.NO .: . 33 46,3 Licensee: Xedd A Signature LTC.NO.: (If applicable,enter "exempt"in the ligense number line.) Bus.Tel.No.- Address: I 1Y Cj('t � / Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Wpartment 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)El owner El owner's agent. Owner/Agent Signature Telephone No. I PPRUITFEE.- $ ro The Commonwealth ofMassachusefts Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 vwW-mass.govIdla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizationJJndividual): rict S Address: Al City/State/Zip: 1 YO 6 Phone#: S W17 00 Are you an employer?Check the appropriate box: - Typo of project(required): 1.El I am a employer with 4. n I am a general contractor and 1 6. E]Now construction pdiployees(Rill and/or part-time).* have hired the sub-contractors . 2.[R I am a sale proprietor or partner- listed on the attached shoot.I 7 F1 Remodeling ship and'have no employees These sub-contractors have 8. F1 Demolition working for mein any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its I 0.FJ Electrical repairs or additions required.] officers have exercised their 3.El I am a homeowner-doing all work right of exemption per MOL 11.E]Plumbing repairs or additions myself.[No workers'comp. c. 152.,§1(4),and we have no 12.Q RoofrepEdrs insurance required.] employees.[No workers' 1311 other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they Aic doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of 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 caul job site information. Insurance Company Name:. Policy 0 or S elf ins.Lie. Expiration Date:_ Job Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 DIA for insurance coverage verification. Idohereby cerilo under the pains,,�an�ddnalfies ofperjury that the information provided above is true andcorrect. Date: Sim a: Phone#: Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License 9 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 N: R 'Y � ,,; , -� �✓x� � � �", _ „r,,,✓� �r ✓�,,�+,r, „r✓,i �J� '�w f �r Pr r �llt7 �r � rr�" � 3r''��t��'r��%a� ✓l✓��rt .. ��U`1 v✓✓i��'��'s ��t'�"ui��`r✓r �t�p✓r� r q i>� tiJ f ��i rraf✓4i✓�✓�F�'�i��'r t}t7 r .i / ��/SSI��f ��e?��'��r 3�✓r�i��fi��f�� >r i/"t r ✓%n� ✓1r P lr ✓r �✓ r rttr?ihti �!✓ - ��7J(L p(��✓ri�✓� ✓ ! i +1�'i r y '7�;ti �J��r y l:'��C%��G�l�t� ��rU✓ €6��' r �r� X 1'� &r r "bT r ;e�' �t r e yfih �' r 2 .3 ,,,r „r -0s za. . � �' � � 'Kp �( I i� 9 �S Llj+� {�/ �)�� //nip j�I�� Jf p�;) �� lF�0 �/F� � � �I )�n(R / �� ry1 l�l � ( l �rg7 ti� 'Il�^frt�f��/G ��19,J� r ��^ l r� it �7t��r� I� l�£�f1}Ijt�tlir�l � r �� f l�Sr k�r� Ao�4��t✓. sJj rl /r 1ti�14't s f •, ✓ r� J H r � ,✓i 3 >IIY ii/r p r t � rtp �,�°e} ✓��5�F3�7 �lrrf l�/Cltt�i{�" `� / '�� g �� t ✓ ,✓ r d r- i ✓ �., p��G>��y� y✓1��l�� rJts r ✓C} i r4' � � � ' �e� r'a�r" � �' r y� y fr s v Ii r r� ��ln z�r%1��`t�/�s �+� 1 r �� t � � r ✓f � i 1 P M f 9�AI�"�/�,�IJ{' fl✓��l��d✓�� p r✓ �� h,,. r j�f �,��f+�r��r��J fi �'r}t��Irj/��,(r�� j �y��t" �+ !/� r� � ^�7UJyty��n t��/r�fl�fi t�� r �✓ r