HomeMy WebLinkAboutMiscellaneous - 153 Raleigh Tavern Lane t
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3?�at�''* °•°"ao� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
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This certifies that ......... ........ ../ .......................................
hET permission to perform /J� f'( ���..A �� C, .
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wiring in the building of.......ln�.......&e...........................
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ELECTR(CALI SPECTOR
Check # o 1
46 � 5
Official Use Only,
Permit No.
a%antrxrsct°��u8ltc Sadet� Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CM 12:00 ,
(Please Print in ink or type all information) Date T' X
To the nspecto of Wi es:
Townof North Andover
The undersigned applies for a permit to perform the
electrical work described below.
Location(Street&Number / ✓ 1/
Owner or Tenant C ,p
Owner's Address
Is this permit in conjunction with a1building permit Yes No ❑ (Check Appropriate Box)
Purpose of Building ��� 1 AMI/V Utility Authorization No.
Existing Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters
New Service Amps VVoiitts Overhead El Undgmd ❑ No.of Meters
Number Feeders and Ampacity �
^ o c`"`� t of
Location and Nature of Proposed Electrical Work Ar 4 441 0A 114 6h,
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
Above ❑ In ❑
No.of Lighting Fixtures Swimming Pool grad ❑ gmd ❑ Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets .3 No of Gas Burners FIRE ALARMS No.of Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.orAI osal No. Pumps Tons KW No.of Sounding Devices
No./of Self Contained
No.of Dishwashers Space/Ar a Heatin KW Detection/Sounding Devices
❑ Municipal ❑ Other
No.of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Signs Bailases Wiring
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
1 have a current Liability Insurance Policy includi pleted Operations Coverage or its substantial equivalent Q NO =
valid proof of same to the Offi YE — NO = If you have checked YES ase indicate the type of coverage by checking the appropriate box
INSURANC = BOND = OTHER = (Please Specify) mn,
(Expiration Date)
Estimated Value of 5lec ical Work$ /
Work to Start G(/ Inspection Date Resquested ��/.Cif Rough Final
Signed under Pe ies erj ry: °
FIRM NAMELIC.NO.�/JL
Lcensee 1tqa / A k
y
Signature6-,-),),— /� LIC.NO.
�y /7 rA-3 �� ��i(IN), IVY Bus.Tel No. ���`7 �
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Address Aft Tel.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)Telephone No. PERMITfE6$ ��
(Signature of Owner or Agent)
u
The Commonwealth of Massachusetts
Department of Industrial Accidents
d Office of Investigations
Boston; Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
- �
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for rry employees working on this job.
Company name:
Address
City. Phone#.
Insurance.Co. Policy#
Company name: ,
j -
Address
Cify Phone#
Insurance Co. Policy#
Failure to secure required under Section 25A or MGL 152 can lead to the' dron of criminal of a;fine ; s
coverage reel rcnpos penalties up to$1,5019W
and/or one years'imprisonnxwA_s veLas_civil.penattiesblhelann-dASTOPMWDPMFR-md-afineW_(,3IIlom)-aday-g iine ,
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/do hereby certdy under Ure pains and penalties of perjury t/>at the information provided above is true and correct.
Signature Date
Print name P.hone.#
Official use only do not write in this area to be completed by city or town officiar
City or Town Perr itUcensin4.
D ,
Building Dept
DCheck if immediate response is required . � LlcefminCg Boafrl
D Selectman's Office
Contact person: Phone A D Health Department
D Other