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Home My WebLink AboutWire Permit - Permits #12569-1 - 24 EDMANDS ROAD 8/10/2015\\ Date.... \\ \\ ...... in . im ISOaark ` ME TOWN OF NORTH ANDOVER 0PERMIT FOR WIRING � \g` * ,+r SS"�CHU o0 \\ el A N \� This certifies that . O \� ... .. �} IN c� has errnissn to perform ag ............................... ......... ... ................................._... Wffil _-ME MINE- wiring the building : INN �O-,\--e, at ........3.� ..... . ... .. .... ..... ........; ...... �...... {? Andover. Mass. \, . Fee<; laic. o�. ..... .... ...... ,.,.. .. . ,. ........................................ \ .... . .. .... .. ELECTRICAL INSPECTOR \\ Check , 11 Z Commonwealth of Massachusetts official Use Only Permit NO. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. im] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PNNTININK OR TYPE,ALL)NFORMATION) Date:&,q lo, sols-.-- 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) ��,(04 0't Owner or Tenant Cx (Yre-e Telephone No. _lq 1 �kes��o� CQ�o, lk-Ar�1 Owner's Address 57A,*e Is this Permit in conjuv4 ion with a building permit? Yes ff No F1 (Check Appropriate Box) 9 Purpose of Building_ Utility Authorization No. Existing Service— Amps Volts Overhead El UndgrdF] No.of Meters New Service Amps Volts Overhead El Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: pt!p kL tr Completion of the following table may be waived by the,Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above M In- No.of mergencyLig ting grnd. " grnd. El Batter v Units No.of Receptacle Outlets No.of Oil Burners FIRE,ALARMS No. of Zones of Detection and No. of Switches No.of Gas Burners No. Init ating Devices No.of Ranges No.of Air Cond. Tons Tot No.of Alerting Devices al No.of Waste Dis Heat pump I Number jj�A� J.KW........... No.of Self-Contained posers Totals: ....... .......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal ❑ Other 11 Connection c—j! No. of Dryers No.of Heating Appliances KW Security Devic ty8ystems:1 Devices or Eg ulvalent 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 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 MECRuIc 10,and upon completion. electrical in 0 unless INSURANCE COVERAGE: Unless waived by the owner,no permit for the performanceofel ctri alwork may u 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 RI BOND El OTHER 171 (Specify:) I certify, under th 1 and enalties iat the information on his application is true and complete. his FIRM NAME: A LIC.NO.: Licensee: t Id li't Signature LIC.NO. (If applicable,e4er7empt"in the license num r line) e" Bus.Tel.No.: Address: -5 ZLeeg IiOI/0,0- Ale�14'141t,' k41-110 — Alt.Tel.No.: *Per M.G.L c. 147,s.-40-61,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)[]owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ..'(`he Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA.02114-2017 ~ wa www.mass.go*v1d1a " Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE 1.'ERM[TTING AUTiMli,`Y. Please Print Legibly A 'licant Information Name(Business/Organization/Cndividual):_ c� Address: Phone#: �"C-- �`� 5' `�. City/S ta-tc/Zip• � ��o w hrL , . Are you an employer?Check the appropriate box: Type of project(required), em to ces frill and/or part-time).* 7. ❑New`donstruction 1.�I am a employer with P Y � 2.0 I am a sole proprietor or partnership and have no employees working for mein 8. ❑Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.❑lam a homeowner doing all work myself[No workers'comp.uisurance required.]' 10 f ]Building addition q,❑I am a homeowner and will be luring contractors to conduct all work on my property. I will 11.LM Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole bin repairs or additions proprietors with no employees• 12.LJ I?lira. g p 5,0 I am a general contractor and I have hired the sub-contractors listed an the attached sheet. 11[]Roof repairs These sub-contractors ha46 employees and have workers'comp.insuranm$ 14.'rl Other — 6.Q We are a corporation and its,officers,have exercised their right of'exemption per MGL c. 1 S2,§1(4),and we have no employees.[No workers'comp.insurance required.] *P ny applicant that checks bbx#1 must also fill out the section below showing their workers'compensation policy infor anew mation. avit fi homeowners sub s must attached an additional cating they are sheegshowing he name o£tl e all work and then hire usub contractotside rs and state wrs must hether r or no those, ntit ess,,have such. tCantractors that employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for°my employees. Below is the paZicy arzd job site information. Insurance Company Name'____._,___--___.__. Expiration Date:. Policy#or Self ins.Lie.#: r `f rt� �� _City/State/Zip: t ! � Sob Site Address:_ Attach a copy of the workers' compensation 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 facie up to$1,500.00 and/or one imprisonment,as whis statement mlay be forwarded to the Office ell as civil penaties in the form of a STOP Of luvOgatioRK ORDER nsof theDIA for insurancd a fe of up to e a day against the violator.A copy of coverage verification. X do hereby under tl s pe a f perjury that the information provided above is true and correct. Date: &P `a Siattu e Phone#: 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 Phone#• Contact Person: - ❑ 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 pen-nit 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. ❑ The Permit Extension Act was created by Section 173 of Chanter 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. • Rule 8—Permit/Date Closed: Note:Reapply for new permit 0 • Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0Re-Inspection Required Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 151 Failed Re-inspection Required Inspectors Comments: ------ Inspectors Signature: Date: ROUGH INS CTION: H')U�'� — Pass M Failed Re-Inspection Required Inspectors Comments: Inspectors Signature: Date: If—/If FINAL INSPECTION: Pass n? Failed Re-Inspection Required Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold a@townofinerrimac.com