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Home My WebLink AboutMiscellaneous - 26 Clarendon Streetf'. Date .. :,�-. �¢..."..1.4........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .........,!„G11/A�/........../t....v...!��....................................... has permission to perform ......../': 11.(../1,1Lsf(........ / 4,. �`'.......!.... ...f.. �1 ..::. _ jr ....... wiring in the building of.......�^. i (1'1 eG1 M ......................................... .............................................. at .... ::... (.... (.... ...... r'L........................... , North -Andover, Mass. Fee..//*ti....�.......... Lic. No. 5..�..................('`..."..`.......'..�....%......::... ELECTRICAL INSPECTOR Check # Commonwealth of Massachusetts a Department of Fire Services ,M BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod (ME ), 527 CMR 12.00 (PLEASE PRINT IN)NK OR TYPE ALL .INFORMATION) Date: JItj16 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) Owner or Tenant 7TCAM Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ N (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service 20� Amps /20/ 2Y0 Volts Overheadf& Undgrd ❑ No. of Meters 2— New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Yv1t'-(, /)—oS{ 2r-' r%ajr ()oif S fib-- Tui. Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cel Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers P HeatPump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Y 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. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Atiach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work:SOc7 (When required by municipal policy.) Work to Start:/ 9(G Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE)RAGE: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties gX'perjury that the infornsation on this application is true and complete. FIRM NAME: .FA W I n 0ffA -1 Cl ' LIC. NO.: 52(oZ3 -R Licensee: f, Niro tkye4 IG. Signature _ LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department 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 my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ %! d Signature `_ Telephone No. The Commonwealth of Massa.chusetts Department of IndustrialAccidents - d 1 Congress Street, Suite 100 ' < Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 'Edwk--, /, Please Print LeLyibly Name (Business/Organization/Individual): lswk--, d0', leleChJC{W Address: TL_ Tiivi nbrpQe_ RX City/State/Zip: �O Qrn , " 0337 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am.a employer with employees (full and/or part-time).* 7. E] New construction Z am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E] Building addition ensure that all contractors either have workers' compensation insurance or are sole 1 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ p 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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' comp. 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: _T[IQ �br-i�_d . Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: 26 C lG1 r-erOOY) 4 k City/State/Zip: M- AYYAOVY ,'MV4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepaai�nannd_penalties ofcp�erju-ry that the information provided ab119 ve is true and correct. Siunat�rre- /A/l Lam/ 1v�2p rte -'1 TY �'�� 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 #: 52623-B License No. Commonwealth of Mas usetts Divisionof Registrati Board of Electri EDWIN �W 246 BRUiff " to Journeyma e t008950 07131/2016 f * Af SJ 0 Expiration Date. Saria! Va.