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Home My WebLink AboutWire Permit - Permits #10579 - 120 MAIN STREET 1/10/2012 � /// / XIM1fS��tt�f��haQ@i��Nl�(VS/��j�V�Vi�(M1I(f��f��Y�� IKhl�lhrt��l�(II�i�WI( /�«II��M1II�f�ifl��OhR��hR� ((��(K@ r�r a e y 4 LL ° s i, 4✓ w� m « m lsj ot a awm w 04 .c MOON Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 7 / BOARD OF FIRE PREVENTION REGULATIONS Date Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CNIR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1/1/12 City or Town of: North Andover To the Inspector of ires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street& Number) North Andover Public Buildings Map: Lot: Owner or Tenant Town of North Andover Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes F-1 No Z (Check Appropriate Box) Purpose of Building Schools&public buildings Utility Authorization No. Existing Service_ Amps Volts Overhead F] Undgrd n No.of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Throughout North Andover Completion of the following table may be waived by the Inspector of'Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above o In 0 No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.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 No.of Waste Disposers Heat Pump I.NP.m.ber.. Tons KW No.of Self-Contained Totals: -1- _ 'I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal 0 Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: fleaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Yearly Maintenance Permit Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $25,000.00 (When required by municipal policy.) Work to Start: 1/4/12 Inspections to be requested in accordance with NIEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licen- see 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 Z BOND R OTHER F-1 (Specify:) I certify, under iltepains andpenalties qfperjury,that the informatio this application is true and complete. FIRM NAME: Andover Electric Services, Inc LIC. NO.: 14302 Licensee: Robert J. Branca Signatu.6/1 LIC. NO.: *Per M.G.L. c. 147, s. 57-61,security work requires Depa ent ublic Safety"S" License: LIC.NO.: S:--- (If applicable, enter "exempt"in the license number line.) ?" Bus. Tel.No.: 978-475-4995 Address: 19 Dale St, Andover, MA zip: 01810 Alt. Tel.No.: 978-423-8350 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below,1 hereby waive this requirement. I am the(check one)El owner D owner's agent. Permit Fee: $ ❑ Owner/Agent Signature Phone: I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite I00 Boston, MA 02II4-2017 www. ass.gov!dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/C7rganizatiott/l:ndividual): Andover Electric Services,Inc. Address:19 Dale St City/State/Zip:Andover, MA 01810 phone#:978-475-4995 Are you an employer?Check the appropriate box: Type of project(required): 1.[✓ I am a employer with 5 4. n I am a general contractor and 1 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ® bemolition. working for me in any capacity. employees and have workers' 9. ®Building addition [No workers' comp.insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 1.0.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL, 12.[] Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors 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'camp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Chartis _ ___._.. —_._.. Policy#or Self-ins,Lic.#:WC 9763814 Expiration Date:4/28/12 Job Site Address: City/State/Zip: _ __ .-- V --.-k h Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A.of MGL c. 152 can lead to the imposition of criminal penalties of a w 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. I do hereby certi under the gains and enalties o !: a that the in ormation provided above is true and correct Si nature: Date Phone#:978-423-8350 Of use only. Do not write in this area,to be completed by city or town ociat City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town.Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: