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Home My WebLink AboutWire Permit - Permits #10578 - 430 OSGOOD STREET 1/10/2012 \' MME I M � Um Date,..... . ... .............., \ IBM% la �QIODINE, �THww, MI, - } tt LtO !� \\ " T T' N OF NORTH A DOVE \\ i IN PERMIT FOR WIRING \�� Ss�1CNUs� \MMIM .I \\ 1 rtlf?eS that .... .....: ..:..::...., -............. \ ................... .... `: \\ has permission to perform ....:.... ............. ........ .:..;..... : .................. A o \ wiring in the building of. .. r . .... . a ; \ Is �` IS at . ..: ............. . .................. dov . v , .. .. No s 1 \ -Eli � . y_ ..................... �.I . moo. ,.,,...,..... .,.....,_._. � . . '. .. _ .... V� ELECTRicAL�INS Ec ro \\ ME II Check # \\ 1\ W Bit U d Commonwealth of Massachusetts Official 1,Jse Only Department of Fire Services Permit No. lCS779 BOARD OF FIRE PREVENTION REGULATIONS Date Issued: rs 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: 12/29/11 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) North Andover High School Map: Lot: Owner or Tenant Town of North Andover Telephone No. Owner's Address 430 Osgood St Is this permit in conjunction with a building permit? Yes ❑ No Z (Check Appropriate Box) Purpose of Building School Utility Authorization No. Existing Service Amps Volts Overhead F1 LJndgrdF—1 No. of Meters New Service Amps Volts Overhead ❑ Undgrtl[ ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Generator Room Completion qf'the J61lowing table may be waived by the Inspector offires. 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 F� In- R 'N-575-TYm—ergency 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 ..Num.ber'.... Tons KW No.of Self-Contained ............ ..................... ................. Detection/Alerting Devices Totals: No.of Dishwashers Space/Area Heating KW Local F-1 Municipal El 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: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassa2e Bathtubs No.of Motors Total HP Telecommunications Wiring: INo.of Devices or Equivalent JOTHER: Remove and replace transfer switch 400-amp Attach additional detail if desired, or as required by the Inspector of'Wires. Estimated Value of Electrical Work: $I Lgoo.00 (When required by municipal policy.) Work toStart: 1/15/12 Inspections to be requested in accordance with MEC 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 M BOND ❑ OTHER E] (Speci - I certify,under the pains and penalties of perjury,that the inform on s plication is true and complete. FIRM NAME: Andover Electric Services, Inc LIC. NO.: 14302 Licensee: Robert 3. Branca S, atu LIC. NO.: r gf*Per M.G.L. c. 147,s. 57-61, security work requi?re ?epairl of Public Safety"S"License: LIC.NO.: S: (I(applicable, enter "exempt"in the license number li e.) Z� Bus. Tel.No.: M-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 by law. By my signature below, I hereby waive this requirement. I am the(check one)D owner El 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 100 Boston, AM 02114-2017 www.mass.govldia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians[Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 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. ] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. F-] Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance,: p required.] 5. ® We are a corporation and its 10.❑ Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their I I.Q Plumbing repairs or additions myself [No workers' comp. right of exemption per MGI, 12.® Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ tither_______.____ 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. I 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: .,(41 C'N \ C>.,�w( -f30 6�r Ci tate/Zip: _ .A16 1 tit t/ 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 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 er`u that the in ®rmation provided above is true and correct Si nature; Date Phone 9:978-423-8350 Official use only. Do not write in this area,to be completed by city or town official City or Towns Permit/License i# 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#: