HomeMy WebLinkAboutMiscellaneous - 41 Milton Street 4
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TOWN•OF NORTH ANDOVER
y PERMIT FOR WIRING
This certifies that . . . . .1 ► # /a, ell-m p(-4. ,-� r C 5Ery
has permission to perform . . . . /is A-RA't, `
�.
wiring in the building of . . . .
at . . �
/l 1_7.0 . • • .`. . . . . . . F�No h Andover, Mass.
Fee'.3S . Lic. No. . .� OICAL
ELE INSPECTOR
Check# 3
11035
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be_deemed-by-the.Inspector_of-Wires abandoned_and_invalid-ifhe—__. ._
or she has determined that the authorized work ha,not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shdll be permitted for reasonable cause.A permit shall bAermi ated upon the written
request of either the owner orthe installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending"through August 15,2012.
t0ku1e 8—Permit/Date Closed: L' I Note:Reapply for new permit /
❑Permit Extension Act—Permit/Date Closed:
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monweaAk of//(aejacLetta
Permit No. L/
_ _ ; _- =' aL.lepartment o��ire�er•vice9 � �
~ Occupancy and lee Checked
- �" BOARD OF FIRE PREVENTION REGULATIONS ;[Rei. 11071 (let1ei,,ai11
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All%\ork to be pertorrned in accordance%% ih the\iassachuseus Electrical Code(\IEC).527(AIR 12.00
(PLEASE PRI.VT L\'INK OR T)PE ALL LVOM4770.'\') Date: 13- 111A - 10-
Cit~ or'I`oii'n of: AJ6jCn AYl h8U V 1 \tfte Irrs��ector of i'F'ires:
B) this application the undersigned gives notice of his or her intention to perform the electrical.cork described below.
ST
Location (Street& \umber) 1-11 ,(Yl i O U(\ g� F\06j?_,
Owner or Tenant e-(-\(A 0 PAS g Telephone'No. S:3 12S 1y9�
Owner's Address S qme
Is this permit in conjunction with a buil in-,permit? Yes Q No ❑ (Check Appropriate Box)
Purpose of Building 2- rA \ UtilityAuthorization No. /V �
Existing Service ZO 6 Amps / ydVolts Overhead K Undgrd❑ .No. of Meters _
.New Service ;imps --^7"'-� Volts Overhead❑ [.'ndgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and.Nature of Proposed Electrical Work:
Vll GL C
Completion of the ollowine table arm be a aired by the Inspector of 1!'ires.
.No.of Recessed Luminaires No.of Ceil:Sus Fans No. Total
p•(Paddle) Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- . o.o Emergency Lighting
.No.of Luminaires Swimming Pool rnd. rnd. ❑ Battery knits
No.of Receptacle Outlets .No.of Oil Burners FIRE ALARMS \o.of Zones
No.of Switches .No.of Gas Burners .No. In
Detection and j
itiatine Devices
Tota[ j
.No.of Alerting Devices
.No.of Ranges No.of Air Cond. Tons iI
Hon
eat Pump \umber Ts K\\' \o.of Self-Contained
.No.of\\'aste Disposers Totals: Detection/Alerting Devices
.No.of Dishwashers S ace/Area Heating ti\\' 11 Local❑ Municipal ❑ Other
P g d Connection
No.of Drvers Ideating Appliances Security Svstems:*
.No.of bevices or Equivalent
No.of Water K\\. No.of No.of Data Wiring:
Heaters Sims Ballasts No.of Devices or Equivalent
No. 14 dromassage Bathtubs \o. of Motors Total IIP Telecommunications Wising:
y b .No.of Devices or Equivalent
OT14ER:
.4t1ach additional derail if desired.or as required br rhe frrspector o!fires.
Estimated Value of Qjectriical \York: (When required by municipal policy.)
Work to Start:_ (� 12 Inspections to be requested in accordance with VlEC Rule 10.and upon completion.
INSURANCE COV R:1. E: Unless waived by the owner.no permit for the performance of electrical work ntay issue unless
the licensee provides proof of liability insurance including-completed operation'' coverage or its substantial equivalent. The
undersigned certifies that such coveraac is in force.and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
F1 /YjQ 1.1C. N0.: A �(.9/�
Licensee: iY1rLR4A /_i(6" Sirnatu IAC. No
'Ifopplicahle. L'111(11. �t}}-,inl ..in the licence mann or-linea /� r d Bus. Cel. \o.m
Address: QQ /t12171lr0e 2 QStu /)1 Q1 !/Z Alt. Tel. No.:
rPer\i.G.l.. c. 1.17.s.57-61.security work requires De�tcnt of Public Safety'•S•'License: Lic. No.
OWNI-R'S INSURANCE WAIVER: i ant a\\are that the l.icensec doe's not have the liability insurance co%crage normally
required by la\�. 13V nn sigrtat:rre below. i hereb\ \\ai\e this requirement. 1 am the(check one)!owner ----- owner's anent.
a t•I:x�e2n[
Sign3S
Signature TelephonePERMIT FI:E: S-\o. �
The Commonmvetilth of 1lassuchuselts
Uepurtment of Industrial Accidents
_ *4 Oiftce of hivestintrlion.s
600 Wflshimyton Street
L; Bostoti, 1L 101111
:. ►rWII%Mas.s.(1otldiu
Workers' Compensation Insurance :kffi(laN-it: Buil(lers/Contractors/l::lectricians/l)iuntbers
Apl)licant Information Please Print Legibly
Name au-..mess t):,,.tt:a; -
m f
Address: . ... ...( C, _.._L
CiP L7 ty/State/Zi : dMeS P --1 . Phone
_ -- - - --Are you an employer? Check the appropriate box: t Type of project(required):
1. I am a employer\with _ I 1. 1, 1 (1, t`t 1 ani a general contractor and I ��--lt
Nem"construction
erripiovees(full and oi•part-time). have hired tl]e sub-contractors
4. listed on the attached sheet. 7. Remodeling
?.❑ I am a sole proprietor or partner- ,
ship and have no employees These sub-contractors have S. Demolition
\corking for me in an\ ca acit\. employees and have\\orkers' j
V P + 9. C Building addition
[\o workers* comp. insurance comp. insurance. :
required] s. —11We are a corporation and its I O.0 Electrical repairs or additions
Q i am a homeowner doing all \wdk officers have exercised Their { 11.0 Pltallhing repairs or additions
ri-ht of exemption per MGI_ , i
myself. [\o workers' comp. i_.❑ Roof repairs ,
insurance requir\d.� " c. I�2. 31(4).and\\e have no
employees. [\o u-orker, l 3.0 Other
comp. insurance required]
*:\n\applia na tial a!tet',:s oox-! must,aho tut out the sect.on belo\\shwc:ra t}teir\\orkcr, a,tt:fie::;atioa polio_ taorr.:ation.
l{o:;Teo\+ne,s\\ho subunit bis w'fidm is indicat:ne the\are doin a!1%\mk and thea hire: :ride cortraciors must sub:rn a;e\\autda\it indliaaut:g such
Cost:ractnr.that,:heti:this Nix inust auached a::acdi:iena,sheet she\\tna tae name oi'tile sub-ao.araators ane:suue\chetaer Lir not utose einities I;. e
etaplm ees }!ih s:.b-a tu:aawr.iia\a et::plo\yes.the\ r:us:pro\rde their \\ov erscomp_pulit\ ruatber.
1 am«t employer•that is prt)rit/t)ig lt•orkers'C'(lttipeiisatioii tlistirititee for ilii.eitil)lo.i,ees. Beloit-is the poliq and job site
in f mmition.
Insurance Compan\ Na4lic.- .. T d,�
Polio" - or Sell-ins. L_ic.==: ._. _. " C'r..l..L-.tD_3_SJ
Expiration Date: _.A2 — �0/�
\
Job site Address: 1 I l T U11 S , cit\
Attach a copy-of the,.corkers' compensation polic\ declaration page(showing the poiicN'number and expiration date).
haIlU1Y to seeUr::CU\'c'i'aLe as i•egliilY,d t.nt.t.l'Set:il0t1 25A UI .\iGL. e. 152 can cttC. ,O the lll)OslilUil ofcriminal penalties 01 £t
11111C tip to S 1.500.00 and or one-\ear un Pr;:soil mew'.as well as c:\it penal:ies in the fortis o a STOP WORK ORDER and a tine
UI un it)S-150.00 is da\ the Gioia:or. Be a(\"isc. .'ai a col)\ o1 ,:pis sta:easels: Ira\ ;)e 'l)r\\arded ilk Lle Oi` cc o1
Itn\.'�ttL'atlU;iti C4 )lie DIA for inSUrance co\era,e
I tit)herelrt'certt'f'it ul' ii s(1tul whies gf'peijw-V that the hifin- moon provided above iS trite and correct.
S na. D2_e. Lit
�� Uitk'iul a\e itnh'. 1)u rtrt write in tlti.c urcu. iu br cvunp/cical hl•cit;'ar tuttvt trffic•iul.
E ( it\ ot-To\\n: Permit.i.icell,e:
I Issuin'-) \tlthorit\ (circle one):
I. hoard of health 2. Building i)cpirtment :. ( ih:la\cn C Icrk 4, Electrical Ina]cctor Plunihin" In>pertor
it. Other !
( ontact Person: Phone=: