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HomeMy WebLinkAboutMiscellaneous - 5 Garden Street 5 GARDEN ST BUILDING F Date.................................. ` � NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SS�cMusE� Smarr � Fi� 1/3 ( �A This certifies that ..................................�...............�......:...�.................... has permission to perform .....?�A.RPJ.0.......tojO? ............................... wiring in the building of......................[.'i I". ...... ................. .North Andover,Mass. E Fee.2.5......©_ . Lic.No...U��.7.-.6... .P.11;k r7 ELECTRICAL INSPECTOR P Check # — Y 7385 (fommonwea&of Vamac"Ih Official Use Only 2epadmed of,}ire Service] -/ e] Permit No. 3 2�,< ' BOARD OF FIREOccupancy and Fee Checked .PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),V7 CMR 12.00 (PLEASE PRINT IN INK OR TY LL INFORMATION) Dater City or Town of: E To the nspector 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 Tenanttf� �`. Telephone N Owner's Address %AJ Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. � _Ito 92 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service f0 Amps /1W/2Y(5Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity �►�`^ , �rJ' �/ Location and Nature of Proposed Electrical Work:. `® � ✓�iYLI 1'�C�y 4 Completion o the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceff.Susp.(Paddle)Fans No.of Total Transformers KVA No,of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- of Emergency Lighung rnd. grnd. Battery Units No,of Receptacle Outlets No.of Oil Burners. FIRE ALARMS TNo.of Zones No.of Switches No,of Gas Burners o.ot Detection an Initiating Devices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices No.of Waste Disposers Heat Pum umber Tons W No.of elf-Contained Totals: "' ' """'"""""""""""""""""""""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems:* No.of Devices or Equivalent Heaters No.of Water KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications iring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Wo (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 iability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that suc co rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURAN BOND ❑ OTHER ❑ (Specify:) I certify, under the pains nd penalties of erjury,that the informa ton on this application is true d complete. FIRM NAME/__X34 �� LIC.NO.•�7— License ��� Signature LIC.NO.: (If applicable,enter "e empt"in the license number line.) us.Tel.No. Address:,_ j /`" �� .lW� �r7 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ i The Commonwealth of Massachusetts A Department of Industrial Accidents Office of Investigations *� 600 Washington Street t Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):�� Z-Io Address:�TLA�, /,�A City/State/Zip4�/1'E:W1)6L/ Wlq lj K' Phone #: '?7 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction 2Xemployees(full and/or part-time).* have hired the sub-contractors am a sole proprietor or partner- listed on the attached sheet. t EJ Remodeling 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. ❑ We are a corporation and its required.] officers have exercised their 1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 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 for my employees. Below is the policy and job site information. Insurance Company Name: Policy#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 certi nder t 'ns en of perjury that the information provided above is true and correct. Si natu Date: Phone#: ei-774S 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#: