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HomeMy WebLinkAboutMiscellaneous - Suite 190-1Z 0 Date..F�/7-l?00.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ...... .............................. has permission to perform,.•`-r'----��� - ................................... ........ wiring in the building of 4.c�? . . ................................... ................. .......... ...... o ........... North Andover, Mass. Fee A ... 12-0.. Lic. N4 //X-sj .......... ........ rR� ..... ALEcmi Check# 2 3 Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. -- ��l� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeM C) , 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: IV C9 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned `` gives notice of hi or her intention top orm the el trical ork described below. Location (Street & Number) `'t��4 q' Owner or Tenant N A ©(� Owner's Address S rr Telephone No. Is this permit in conjunction with a building permit? Yes Ef� No ❑ (Check Appropriate Boz) Purpose of Building C) L_1�__� M , Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r1(1 \ n r� c�'l 1► ®� co letion nftho fnlln.lin.>t..hl.�....,,, 1,.,,., :.. 17.,• IL- t-____.__ No. of Recessed Luminaires ---- -------- -.._ ...... ..... No. of Ceil: Susp. (Paddle) Fans .».,... ...»y -1 1-1— yME .�rto cuui uj rr trey. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ ln- ❑o. o mergency Iig ng rnd. grnd. 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 No. of Air Cond. Tonal No. of Alerting Devices No. of Waste Disposers Heat Pump Number _........................................ Tons KW.,.., No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* or Equivalent No. of Water KW Heaters No. of No. of Data Wiring: Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: e1 ` - Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �� C) (When required by municipal policy.) Work to Start: ,9 ii (M 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 liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is ' ice, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:) I certify, under th ins andpenalties ofperjury, that the information on this application is true and compl e FIRM NAME: 1 (�� �',f1 LIC. NO�I Licensee�l &VJ � Signature LIC. NO.: (If applicable, �ex t " in the license numberlin b Bus. Tel. No.:� _c Address: V f j0 C {Y-.*t(Y� d- 2 �'4� Alt. Tel. No.: JB1 `1 (% *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 Signature Telephone No. PERMIT FEE: $ �01/ � ' 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):_ Address: �10 i< Lam _S�7_7 (�R- City/State/Zip: �4� IN02J k'( !'hone Are you employer? Che the appropriate Vox: 1. yoam a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other -Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. + 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: C M r3-, 0 -- Policy # or Self -ins. Lic. #: w �Q Expiration Date: 2 d Job Site Address: City/State/Zip:1 V �i 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 under the pains andpenalties ofperjury that the information provided above is true —and dccorrect. Sian Phone #: E� ok Q=;:,� Official use only. Do not write in this area, to be completed by city or town official, i II City or Town: { Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: