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Home My WebLink AboutWire Permit - Permits #12445-1 - 13 ELMWOOD STREET 7/2/2015 v \ e� §soffit �\ . ' `'• `! e MOR p IRRI ` \ NUMBER Ell i ate;=4¢�Yyy 4� \ \\\ HUSEt \\ a ME � \ ig 1110 met. .k rfoe iggs jrin L �n o mmim at . :_ v 101, IN MERIM \ o\\\\\\IV Check .. _INRE"", ......... Qh \ ISM And \ IN " \ �� r,17, \ MM MM ME WMIN \ \\ `�\\........... M M fl Ill all V� Official Use Only Commonwealth of Massachusetts F Permit No. Department of Fire Services 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(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE,4 LL INFORMATION) Date: 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) /3 4-11 Owner or Tenant Telephone No. Owner's Address 1� 64", Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CoNpletion of the followin 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 Above ❑ In" No.of Emergency Ligliting No.of Luminaires Swimming Pool grnd. grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS JN' o. 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 Heat Pump Number I Tons I KW No.of Self-Contained No. of Waste Disposers Totals: ......................I .............. Detection/Alerting Devices ipal No.of Dishwashers Space/Area Heating KW Local Ei MunicConnection F] Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices orEauivalent OTHER: Attach additional detail iftlesired 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 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. CHECK ONE: INSURANCE '"a ,� BONDEJ OTHEREI (Specify:) I certify, under the ptcdns and Wes,ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: "n Licensee: Signature' MC.NO.: 2 17a, (If applicable,enter "dempt"in the license number line.) Bus.Tel.No.' Address: Alt.Tel.No.. *Per M.G.L c. 147,s.57-61,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. f am the(check ono)[j owner []owner's agent. Owner/Agent Signature Telephone No. [PERMITFEE- $ 5-,5---7 The Commonwealth of Massachusetts z Department of IndustrialAccidents i Wr X Congress Sheet,Suite 100 Boston,MA 02114-2017 www.rnass.gov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE, PERMITTING AUTHORITY. Applicant Information Please Print Lel4ibl g ) 'r1 �� Name usiness/Ox asuzatian/lndrvidual : �.. ,+ i Address " �:�. �.� City/State/Zip: ° � ,..� ��e�� t'� .,°N � Phone # d ' ex Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with, _employees(full and/or part-time).* 7. ❑New construction 2.NJ am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.❑i am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. Other Q 6.❑We are a corporation and its officers have exercised their right o£'exemption per MGL c. 14. --- 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,'they must provide their workers'comp.policy number. 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.#: 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. F` I do .� e �. �..��.... p � p fp � rJ' information provided and correct. Signature: certify-,under the azns and{e alties o er u that the in ormati Dat above is true and v Phone#: ."; Official use only. Do not write in this area,to be completed by city or town official.. City or Town: PermitlLicense# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone#: