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Home My WebLink AboutWire Permit - Permits #9623 - 601 MAIN STREET 9/1/2010 KIM � \ \ \ , Date.................................. \ Oill f pORTM �\ ``o ®c TOWN O T N E- Off\ ERWIRING �\ f, oil \\ 1 ow M =-F g\\ MI vr INSThis certifies that .. ,.. ., . g, - � ........ .... . ....... NMI . - ., has permission to perform .,.. .... :.. ...... .. ... g �\ wiring in the building of.. .,... .. £ `at ..,.,. . ...... .........:....... ......................... . ..,.. , forth Andover, Mass. A 4� y Fee..�:" ........... LiC N{? AAA `\ ELECTRICAL INSOlECTOR_ \ Check # IF \`\ 01 �\ �rrrrrrr��rrrrrr�r%'ir'��i��riir�ir�rr�rr��rrr/r�ia��r�rw'��r�r��rr��✓�rrrrrr�rrrrrr�a�i��i�ir��rr��rrrr/%��ir/�r!rr'��i�rr�r�i�a�rr��rrrrirrerrrrrr�rri�rr��rrrrr'�/�/�l/��1��%�✓��Url �l��r��%��rrr'��/ �„ �r�`; �rF �'' �„ r; c i �' d'<; N; ;`; �F 1„ i i i i i i i u ri ��, r i�, , , , »�, r , r, i r ,r �, ro mn�,r�i ri , vi ,� i � i i r r 7,nr irr�>' irii r r�ir�rr r�ry,rr,ii�r,»r r rryrrl,rry r, > > >irrrrr�r rr >> >ri,r, r, ryi,Yy11 1 Yr. U 1)1 J y JJ)1J)J Jl 1rJJlrJ�J�J� ,J) ��, J) J 1 ,Ir��J1Jl��J1J 11J,JJ JlJ1l„'lll ll„�l�l�.J��l/rll),/rl�,JIl1��JlJJJAI�J)�1JJ)II�J)�l IJI,,JJJr,Jl 1)�J)1JrJJ�1Jlr)yD J J)y)y)l)J).: i��)y��i��r%l��J)��)��1��J)�11�u, � JaJrJ��")JJ��7�1,��J�lJ�rl��1�1� I�JI�I�� 1��IJJI�iJ�/ JJIJJ I)�J 1)��1�/��l/�ir� ,l�)Jr��J�,, I��i)�Jl��I)��I LoUJJJJJJU11VVCa1L11 UY Permit No. ti Department of Fire Services Occupancy and Fee Checked 0, BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQI 7�C R 12.00 (PLEASE, PRINT IN INK OR TYPE ALL 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) 610/1 Owner or Tenant ❑ x C cfe-/z, Telephone No. Owner's Address I il Yes [:]�No��(Chee�kAppr�opriate�13ox)� Is this permit in conjunction with a building permit? Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Uiidgrd ❑ No. of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. INO. No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Tr of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA TT`mergency L No.of Luminaires Swimming Pool Above El In- N—o:—o d. Battery Units ig mgVrnd. grn No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of Detection and No. of Switches No. of Gas Burners No. Initiating Devices No.of Ranges No. of Air Cond. TonsTotal No.of Alerting Devices No. of Waste Disposers Heat Pump I'Number I Tons No.of Self-Contained Totals: I................ ....................... Detection/Alerting Devices Municipal ❑ Other No. of Dishwashers Space/Area Heating KW Local D Connection E] Heating Appliances KW Security s ms:* No. of Dryers No. or Equivalent_.. No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.'of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent OTHER: Estimated Value of F Attach additional detail if desired, or as required by the Inspector of Wires. ,lectrical Work: (When required by municipal policy.) Work to Start: !t471jzz J 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 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 0 BOND n OTHER EJ (Specify:) I certify,under thepp�ai Ondpenaltio-4per/lur ,that th information on this application is true and complete. -9 FIRM NAME: LIC.NO.: Licensee: Signature LIC.NO.: (If applicabTe, ent exempt"ant license number line) Bus.Tel.No.: Address: Alt.Tel.No.: *Per M,0.1,c. 147,s.57-61,security work requires Depart� t 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 rnj,*. ature below,I hereby waive this requirement. I am the(check one)El owner E] owner's Owner/Agent`-,r& FERMIT FEE: $ Si2natu -- Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 19� www.mass.gov1dia Workers' Compensation Insurance Affidavit: Buildet-s/Contractors/Electricians/Plumbers Applicant Information Please Print-LKgjbL Name(Business/Organization/Individuat):_ �zl Address: C", ----------- city/state/zip: :LrPhorie 4: CZJ � -/2ci - S7d Are an employer?Check the appropriate box: Type of project(required): I al I I am a general contractor and I I- I am a employer with 4. F 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 7. E] Remodeling 2.n I am a sole proprietor or partner- listed on the attached sheet.T ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 11.n Plumbing repairs or additions 3.n I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4),and we have no 12.n Roof repairs insurance required.]t employees. [No workers' 13.n Other comp. insurance required.] *Any applicant that checks box#1 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name:—----- Policy 9 or Self-ins.Lic. 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 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 certy�t _y fue aips andpenalties of that the information provided above is true and correct. Signatyrb�"7.1111-111 Date: Phone 4- Official use only. Do not write in this area,to be 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#: �a m,