HomeMy WebLinkAboutMiscellaneous - Exception (219)' Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
N
Official Use Only
Permit No. 17A
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 Electrica4nspv"ctoor
(NEC), 527 CMR 12.00
(PLEASE PRINT W INK OR TYPE ALL MFORMATIOA9 Date:City or Town of: NORTH ANDOVER To the of Wires:
By this application the undersigned gives noticeofhis or her intention to perform the electrical work described below.
Location (Street & Number) / qO 14ti CSO %
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building 5 r' le- Fc m. l Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: &S,mu ✓1i— Rcme .e
r1mmnlatinn nfthv fnllnwino tnhla. mnv he waived by the Inspector of fires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans V
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
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 Disposers
P
Heat Pump
Totals:
Number
I
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
Heating Appliances KW
Systems:'
SecuritNo. o e 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 E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Mres.
Estimated Valu;/if El ctrical Work: i S 7D (When required by municipal policy.)
Work to Start:/ / Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE O 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 JK BOND ❑ OTHER ❑ (Specify:)
I certify, under thepains an penalties ofperjury, that the information on this appli on is tru complete.
FIRMNAME: k1 c. t'F �,J� �f LIC. NO.: 3% $ 3 _
Licensee: Signatur G LTC. NO.:
(If applicable, enter "exempt" in he if nse number line.) Bus. Tel. No.:- It ZK S 75 S� `t 7
Address: YY % r6 ve 1A., ✓c✓�i. ��, �� 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: $
Signature Telephone No.
❑ 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 , If
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 if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the 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.
❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
r
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed 0
t Re- Inspection Required ($.) ❑
Inspectors Comme
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass R
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com