The URL can be used to link to this page

Home My WebLink AboutWire Permit - Permits #12718 - 18 EDMANDS ROAD 9/8/2014 MEM ggg N\ \ "\ \\\ S\ 0 RTC BILL ON OR, 4,&�Q ; �, TOWN OF NORTH ANDOVER AM o PERMIT FOR WIRING \\ - \ ` ,. \\ m g IN 161 tiUB� \ rt This certifies that ..... ..,.. .. \ has permission to perform1-0 .................... wiring in the building af...... ...................................... z r_ ......., MOM, Mqg at a� �\ ME, In .._a_ __.... . . .. a�... s_.. aver, , y lend gnam F .e.,.Q— :... . Lie. No. � CAL scrc� MO _ Check # \ Only Commonwealth of Massachusetts Official Use Department of Fire Services Permit Na. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NIEC), 27 1 12.00 (:� (PLEASE PRINTINJNK OR TYPE ALL INFORMATION) Date: ;> I 1� City or Town oh NORTH AN-OVER 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)--I.e E&Auy\)5 ( ) Owner or Tenant Kf-U� SE�) Telephdne No. Owner's Address Is this permit in conjunction with a building permit? Yes PQ No ❑ (Check Appropriate Box) 4.), r\) 0 _C,�V Purpose of Building Le k Utility Authorization No. Existing Service Amps Volts Overhead El Undgrd❑ 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: E—O-Q S Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires j 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 A ❑ ❑ No.of Emergency Lighting Batter y Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Gas No.of Detection and No.of Switches Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons He ib.91.TqR� JKW No.of Self-Contained No. of Waste Disposers .... ........ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW Na. of No.of Data Wiring: Heaters ..Signs Ballasts Na.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total]UP Telecommunications Wiring: NO.of Devices or Equivalent 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 WC 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 X BOND M OTHER F-1 (Specify:) -1 cerilty, under th a).n,sandpenaltieso perjury,that the information on this application is true and complete. FIRM NAME: CGk-C, C— LI C.NO.:rc <s Licensee: C C Signature LIC.NO.: ,9 0-9 (If applicable,enter "exewt"in the lice e number li Bus.Tel.No.n�>l, Address: \\-k- &V , Kc- -,/" Bus. Alt.Tel.No.: CIO *Per M.G.L c. 147,s.57-6 1,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,I hereby waive this requirement. I am the(check one)❑owner F owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly , \Name(Business/Organization/Individual): Address: 4__ City/State/Zip Phone#: C) a you an employer?Check the appropriate box: Type of project(required): on I J. l am a employer with 4. 0 1 am a general contractor and I 6. ❑New construction e Pyees(fall and/or part-time).* have hired the sub-contractors 7. ❑Remodeling 2.❑ 1 am a sole proprietor or partner listed on the attached sheet.I ship and'have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. workers' comp.insurance. 9. F1 Building addition [No workers' comp.insurance 5. El We are a corporation and its 10.n Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.FJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.E]Roof repairs insurance required.]t employees.[No workers' 1311*other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. fContractors 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 far my employees. Below is the policy and job site information. Insurance Company Name:. C Q) cn_l �4 -kExpiration Date: CK-i" --.'SUAJ `P_ Policy 4 or Self-ins.Lie. E - (3 ci C 4 City/State/Zip:Job Site Address 2 -I C tate/Zip: \A 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1do hereby certi nderMrpams alit of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to he 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 M CT IANS r � � � +!U ��,a ►�r I UNS�E AS A I 1 R �,°LECTR I C I,AN : N Ai kw; s �. EICENSE f f t f , +tiA C E GTR,I,c ! n IgpP, if r �1, ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G1 c. 166, § 32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L, Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. D The Permit Extension Act was created by Se ction 173—of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. Fl Rule 8—Permit/Date Closed: — ***Note:Reapply for new permit El L1 Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed n? Re-Inspection Required($.)F-1 Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n? Failed IN Re-Inspection Required El Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed M Re-Inspection Required L1 Inspectors Copiftlents: Inspectors Signature: V Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required El Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC,MA. .......dweinhold@townofmerrirnac.com