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Home My WebLink AboutWire Permit - Permits #11485 - 51 EMPIRE DRIVE 4/1/2013 _ '\ Rl � . � .: \\ \� mpl Date... �O MM AM ask ,. 8 TOWN OF NORTH ANDOV R S110M\; IT FOR I Iall ` �. � _ 4{s`ao 5 �p1-1 \\\ INNER ��A\ :................................... ............................. »..... d.. . ........Thy certifes that ....... A IN 1IN \ ........ . .................................... \ has p 'ssion to perfc� a ..... � ._, ,.... ...... o lg gm wiring in the building Qf................... ME ;° _ - North Andover, Mass. \\ _ „ ....................... �� at ...:,.. R i ... .. . Lic. Nca #; .......... L. ..,... O \\ �E'e ...... .. ECTItICAL II3SPE( rC3R�� mim gogg _ `\\ Check# = o 0IN Commonwealth of Massachusetts Offl lal Use ral y Permit No. D Fire Services epartment of Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblarik) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PMTININK OR TYPE ALL INFORMATION) Date: ti I 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 'V�z vor 0-(N— Telephone No. (0 (-1 %J Owner's Address Is this permit in'conjunction with a building permit? Yes [A----No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] UndgrdF] No.of Meters New Service Amps Volts Overhead❑ Undgrd F1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W,. f�,�5 Completion o _ector of Wires. res. ,fthe.following Nemaybe waived by eIns p INO.01 Total No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No.of Emergency Lighting No.of Luminaires Swimming Pool fl. n El gril grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones I No.of Switches No.of Gas 13 No.of Detection and Burners Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump I Number I Tons KW No.of Self-Contained No. of Waste Disposers Totals: .......... ....... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal Connection F] Other * Heating Appliances KW Security Systems: No.of Dryers No.i f Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices orEquivalent, , Telecommunications Wiring: No.Hydromassage Bathtub., of Motors Total HP No.of Devices or Equivalent OTHER: r. Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: Ck) (When required by municipal policy.) Work toStart: .. ._Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COV)ERAGE: 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 [9-IBOND El OTHER El (Specify:) S-J� fee,ritry,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LTC.NO.: Licensee: rRcilt,�\ Si2naturc—. LIC.NO.: f� (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: Address: qq 511,,e 4,*L. a,iu-cs c Alt.Tel.No.: 11 *Per M.G.L c. 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 [] owner's agent. Owner/Agent PERMIT Signature Telephone No. FEE: $ Aft The Commonwealth of Massachusetts 1K AkN_ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address:_. Q V-C- A—e-, �4� &Lf_ City/State/Zip:.. VC,A /4 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. El I am a general contractor and 1 6. n Now construction ;eTmyJoyces(full and/or part-time).* have hired the sub-contractors 2.U- Vrn a 5 ole proprietor or partner- listed on the attached sheet. 1 7. n Remodeling ship and have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. workers' comp.insurance. 9. L]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.n Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I1.E1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.R Roof repairs insurance required.]'r employees. [No workers' 131-1 Other comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such' �ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.' am an employer that is providing workers'compensation insurance far my employees. Below is the policy rend job site !formation. isurance Company Name: olicy#or Self-ins,Lic. Expiration Date: )b Site Address:- City/State/Zip: /C) 1tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Fup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify un a-,7 gLus-an4penaldes ofperjury that the information provided above is trite and correct d ,VW-,j, 12nature: Date: lone -75 Official itse 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 9: ❑ 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.G.L 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 pennit 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 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. ❑ Rule 8—Permit/Date Closed: Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Ins ectiion Pass EN Failed Re-Inspection Required ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required ❑ Inspectors Comments; ------------- Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH LXSPECTION: Pass k7 Failed Re-Inspection Required ❑ Inspectors Comments:, Inspectors Signature: Date: FINAL]INSPECTION: Pass N Failed Re-Inspection Required ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com