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Home My WebLink AboutWire Permit - Permits #12875 - 8 EVERGREEN DRIVE 11/16/2015 pp a Elk Iry a = 01 i ow A Ne ...:...,.� ............. ................. ;, IMP \\ µpTy \\ TOWN OF NORTH ANDOVER Ows 01 ANN a I IINIM F IN0 0117MUS IU * n� 1S �� gg ._. \\ This certi fies that ... ..... ... .............................................. \\ ............................... \\ �" has pe ssion to perform ...., . ..:... a ........ 110 �, \giffig `ge s w�nn� in the building of.... . .................. a _... r� .. . �_ ....... .............................. ....... VON`111 \\ gii North Andover, Mass. � �\ z .... ... ..�. ........ at ...... �.......... . ........ . .... .... � A Fee—, . N . MR, .. ELECTRICAL s�EcraR 100 41 \, �\, ()ccLLpancy and Fee Checked EC),,A,PDOl: F r--_ PRE\/EiNiTIO\i �REGULATIONS [Rev- 1/071 (lea,/eblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK A R C7vork to be performed in accordance 17Ath the tV(assachusetts Electrical Code(MTE-C),527 CNIR 12.00 Z , L(,-L_FAST- ,PRD1TflV1_1VK0 =R ALL 1AT0RZVL4T1()N) Datet 0 � ,)I, City or Tor a of- 6�-Yjr�-),P,f," To the Inspector of WiT-es: By this application the Lmdersigned gives notice of his or her intention to perform the electrical work described below, Locatioa(Street&Number) -A :c Telephone Nu.7 Owner or Tenant C 2. Owner's Address Is this permit in iconjuactioawith a building permit? Yes No � (Check Appropriate Box) .,Purpose of BuRding, Utility Authori—zation No- ExIstincr Senice Amps Volts 0-yerhead Undgrd ❑ No, of Meters New Service Amps Volts Overhead❑ Unda d ❑ No,,of Meters NFum b-er of Feeders and Ampacity Locabon and Nature of Proposed Electrical Work- ccimpzetion cftlre./�Wcwmg table map be waived by the Inspector of Wires. No. of Total No. of Recessed Lumijuaires oicen,ssp.(P, ,d(Ue)Fans Transformers XVA �No. of Luminaire Outlets No. of H—at Palos Generators KVA Abo e 0 mergency A- ng Nu. of Luminaires Swimming F901111 i nits arndv d. Battery No. of Receptacle Outlets No- o'OU Burners FIRE ALARMS 11'1io. of Zones I No. of Detection and '�N%jo�f T ]sj_orm p__7addle)�Fams r lNo, of Swit-c-hes JN9,_,)f Gas Burners Initating DeAces No,o)f ranges No-of Air Cond. — Total No. of Alerting Devices `Io1)f fans Heat Pump Number T9&5 o.of Self-Contained lNo.. of Waste,Disposers T�otals.l Detection/Alerting Devices '411 Municipal No.of Dish-washers SpacelArea Henting K10V Local Q [] Vie. Connection y Systezus' No.of Dr-fers Heating Appliances KNV No.-of Devices or E gah/alent JIN70 of Water �No_ of IN 0.of Data Wiring: Heaters Signs Ballasts No.of De-Ices or EQuivalent 4i�l�o, dromassage Bathtubs R Estimated Value of Electrical Work. $200.00 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NIEC Rule 10, and upon completion- INSURANCE COVERAGE: Unless waived by the oTvmer, no permit for the performance of electrical work may issue unless the licensee provides proof of liability iiisiixaiice including"completed operation"coverage Or its substantial equivalent. The undersigned certifies (hat such coverage is in force, and has exhibited proof of same to the perrm',issuing office. CFIE CK ONE- NISURAI\fCE 7 BOMD [I OTffr7R 7 (Specify:) I certify, under the pains and penalties of perjury, that the infor?nation or-- this application is true and complete. Fl_p,ivf NAyLE: DIPIETRO HEATING & COOLING LIC. ,No.:A18265 ERI'K PIERMATTEI TJC.N0..40803E I�`�t> fiCubCe, errs exempt"Licensee. Signature -ur 4n the IZC,-?7 BuN.Tel 978-372-411 1_ Address. -5 SOUTH SU[V(MEP, ST BRADFORD MA 0'835 Alt. Tel. 9 78-994-0725 'Fer M.01. (-,. 147_s. 57-61_5ecurity-work requires Department of Public Safety"S"Lice-ase- Lic. No. "7r�lt "'S ITfSUEtr .ts(C �sAIIEka;: 1 azn aware that Che:Licensee cues not ltictve nc� Iiab�ill y in ura-nce coverage normally c cqui,c�d by (a,,,,,. By =,/,3igrtarurc below, Pacreby this ccquiremenr_ I am tlae (check one, ❑ owner El owner's ag'-:UL �FF: Sign atu_ Te—leptionne T F C"A t Tke c'or man eattth of Af=sackmsetts Deparftwnt of Industrial Accidents Office of Investigations 600 O'ushirxbtars street ` Boston,JIA 0211.1 f y� $1JNw.$lLass.gavI is Workers" Compeusation Insurance Affidavit- BuildelrsIContlractors/Electricians/Pi mbers Appheant Information Please Painlf L 'b INaMe(B-asinessiorganizatiorondividual): "° ? Address: ' ""� C e, City/State/Zip: '" rf f `(w._ ,1 0 -Pho nc#: n .... Are;you an employer?Check the appropriate box: Type of project(required)_ I am employer wittx 4.. I am a general contractor and 1 5. New construction employees(full and/or part-time).* have hired the sub-contractors 2_0 I am a sale proprietor or partner- listed on the attached sheet_ 7. Remodeling ship and have no employees These sub-contractors have g, Demolition working for roe in any capacity_ employees and have workers' g_ Building addition [No workers'cornia_ insurance comp. insurance.t re aired.] 5. F_� We are a corporation and its 117. Elea.tria:al repairs or additions 3.[I I am a homeowner doing all work officers have exercised their l l.F-1 Plumbing repairs or additions to self. [No workers' comp_ right of exemption per tb[CYL 12.n Roof repairs insurance required.]` c_ 152, §1(4)>and we have no l3_ other , employees_[No workers' �� 0i . comp,insurance required.] aAny applicant that checks box#1 must also fi31 out the.section below showing their wrorkers'compensation policy information_ Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such_ tConlractors that check ihhis box must attached an additional sheet showing the nam of the sub-001111actors and state whether or not those entities have =ployees_ If the sub-contractors have employees,they must provide their workers'comp.policy number. i am an employer that,is providing worlren'compensation huarancefor my eniproyees, Below is the policy and job.site inforrartior Insurance Company Name: t`- -- Policy#or Self-ins.Lic.#: � � a Expiration Date: .20 r Ci� � r ( fob Site Address.-A— r t Attach a copy of the workers' ca{m � oa lie declaration page(showing policy number d expiration . Failure to secure coverage as required.render Section 25A ofMCTL 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 fora of a STOP'4 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 ice of Investigations of the f31A for insurance coverage verification. 1 do It r the pains and pe does of perjury that the information provided dd above is true and correct Late: Official use only_ Do not write in this area,to be completed by city or town ofl-ciat City air Town: Permit[Lice nse 4 Issuing Authority(circle one): [.Board of health 3. Building Departmeut 3,City/Town Clerk 4. Eles tricat Inspector a". Plumbing fuspa ctor 6,Other Contact�ers�'u=_._� Phone# r y � �Ui �� CONTROL # C— 3 �J IMPORTANT If your license is lost,damaged or d is inaccurate;or needs toxa corrected,visit our web site mgmass.nov/dp|for instructions to ensure the proper mailing of your Renewal Application and any other correspondence, This1ioenaeio subject o Massachusetts General Laws and regulations. Your license ioa privilege,and cannot be lent or assigned to any person or entity under of law. Keep this license on your person o,posted aarequired by law and/or regulations. ' ` ON §3nss ' ^ ' �