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HomeMy WebLinkAboutMiscellaneous - 12 Ciderpress LA Date.. ........................ NORTI{ TOWN OF NORTH ANDOVER � P PERMIT FOR WIRING ��SS�cHusE� This certifies that ........................v' '' ...................................................................... r has permission to perform ....�.< .......�../'� .:.... ..:.......................... wiring in the building of.../..?"........ .'.. ss.......ly�'. ............ . ......... .................. ".�..... ` •`........ n�. ..... .. .. .. ELECTRICALINSPE p Check # 37&r Commonwealth of Massachusetts7No, Official Use OnlyMAZIRM / Department of Fire Services PerBOARD OF FIRE PREVENTION REGULATIONS OccFee Checked [Rev. 1/071 neave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 MR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION} Date: (, f v City or Town of: NORTH ANDOVER To the Inspector of fres: By this application the undersigned gives notice of his or her intention to perfo the electrical work described below. Location(Street&Number) r i�r•%O/,rlf 5- Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of BuiIdin El NO � (Check Appropriate Box) g— T(�'� P Z�V/ Utility Authorization No. ���' Ys�/ Existing Service Amps / Volts Overhead ',A., ❑ Undgrd❑ No.of Meters New Service L1D Amps. / f( Volts Overhead ❑ Undgrd No.of Meters Number of Feeders and.Ampacity �✓M ��� l��,� Location and Nature of Proposed Electrical Work. Com lesion of the ollowin table may be waived b the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans °•°f Total ' Transformers I{VA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool AboveIn- o.o mergency ig g d. d. Battery Units No.of Receptacle Outlets No.of On Burners FIRE ALARMS No.of 2©IIes No.of Switches No.of Gas Burners No.of Detection and Ranges Total Imhatm Devices No.of Ran N g o.of Air Cond. Alerting Devices No.of Waste Disposers eat PSP Number Tons Tons KW No.of No.of Ale Self- ontained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating Kms' Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KR' Security Systems:* o.of Water No.of No.of Devices or Equivalent Heaters K' No.of Data Wiring; Signs Ballasts . No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring; OTHER: No.of Devices or E uivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: p� • (When required by municipal policy Work to Start 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 i� BOND ❑ OTHER ❑ (Specify:) I certify, under the pa�xx and penalties of perjury, that the information on this application is true and complete FIRM NAME: '�fv, v► /'rrn l�r�Js t �r'c • ` LIC.NO.: Licensee: ,st,J � ��n.� Signature �r (If applicable, enter" mpt"in the license number line.) LIC.NO.: C: 3 5�� Address: TryJ f/-ye�iBus.Tel.No.: *Per M.G. 147,s. 57 61,security work requires Department of public Safety"S"License: Alt.Lic.Tel•No. ` OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ i The Commonwesith of Massachusetts Department of Industrial Accidents Office of Fnvestigations 600 Washingwn Street Bosto►z, M4 02111 www.massgov/dia Workers' Compensation Insurance A�davQt: Builders/Contractors/Electrici nformation ans/Plumbers AD�licant I Please Print Lesibiv Name (Business/Organizabon/individual):_-7 t r. Addtess: City/Sate/Zip: � e,/ Phone#:_ �7 r2. you an employer?Check the appropriate box: I am a employer with�_ 4. ❑ I am a o Type of project(required): teneral contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑Neve construction I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have working for m in any capacity. workers' comp.insurance. 8. ❑Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required] officers have exercised their 10-[1 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.0 Plumbin re myself [No workers' comp. C. 152,§1(4),and we have no g rep or or additions insurance required.] t employees. [No workers' 12.❑Roof repairs comp.insurance required.] I 13-[] Other i A-ny aTM`Ilc'nt that^c1==.a box-#I must jLisU 121:0..t f;CC 3eC.'Q'J^_Lein R•Cr:.'e1S'co.`^;.__�on....i:....Y.�:_.. Homeowners who submit this affidavit indicating the,z e do g all wot'a and then hire outside con do; submit a new afridavit indicating such. 'Contractors that cineol.this box must attached an additional sheet showing the name of the sub-contras-tors and tbeir workers'come.policy information. I am an employer that isproviaing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: ii— Policy#or Self-ins.Lic.#: ('/') Expiration Date: 1�4 Job Site Address: t C/ r'7'jf �js! City/State/Zip: Attach a copy of the workers'compensation policy declaration page (showier 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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form off a STOP WORK ORDER and a of 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 certify unde pains and penalties of perjury thrrr the in formation provided ab ov is true d correct Si�aturP: Date.: Phone#: 7111 /` p �� [6. fficial use only. Do not write in this area, to be completed by eiti,or town official ty or Town Permit/License# uing Authority(circle one): Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector Plumbing Inspector Otherntact Person: Phone#: