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HomeMy WebLinkAboutBuilding Permit #850 - Exception 6/21/2007Permit NO: b BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 6X011 ` DESCRIPTION OF WORK TO BE PREFORMED: U OWNER: Name: I -e Identification Please Type or Print Clearly) Se �/ Ue P c -)--z- 61 + n, Sic u Phone: 9-)R- (a '_�O ?E- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ . °i� (o • Q 0 FEE: $ Check Nq Receipt No.: NOTE: Persons contracting wif unregistered contractors do not have access to,4he guaranty fund Location 'S7- - No. 9 Date TOWN OF NORTH ANDOVER 41 Certificate of Occupancy $ Building/Frame Permit Fee $ HU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 203�8 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS El 1' DATE REJECTED DATE REJECTED DATE REJECTED DATE APPROVED DATE APPROVED ■ DATE APPROVED Zoning Board of Appeals: Variance,- Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NU i t5 anti DATA - (For department use 0 Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 J H � y LLJ z0 C- 5 0 xx o U 0q co r. U u. o W a x O pG G W. x W a W I x O ja x x Q O c�4 Cd G x C y O cn z cn -� E cn J H � y LLJ z0 C- O z1h 4M Icm 'w O •� COD Q V y O ■g m m CL �3 c L e_vv o a CA � c O V 'p O C,Z0 CL � :..± ND � C C COD is 5 0 :o c w„ g c � o ` C y O C 'r O V G3 .Q� CL C ev ev m C :Z O E a , CD c m : 0 d y ■. E c m c$ CO m C 29 CL -- i:CD CD cm O N c :cam p CA m CD O pm m & Lo m o `+mz=vc �: c" c C yQ C� dct O Z O O O CL C_ m ymc c = m C IV � O 4 -CO2 m r0-■ CO ymo� M= -0 CD s W .y .04- JZ .� H cc .LLJ nrm 5 Z C.) E E a m��� 5 = A ` ti O Z.CL O z1h 4M Icm 'w O •� COD Q V y O ■g m m CL �3 c L e_vv o a CA � c O V 'p O C,Z0 CL � :..± ND � C C COD is renewal BY ANDERSEN' window rcpl­c Customer Service 800-573-7606 104 Otis St.- Northborough, MA 01532 - Main: (508) 919.0900 • Fax: (508) 919-0903 J&L Windows, Inc. dba Renewal by Andersen • Contractor License #149601 • Expiration Date 09/23/2008 A WINDOW AGREEMENT SOLD TO: AIC�St., IffOZOIlIM3�/ DATE: ADDRESS: 21 O e4,<� S� ,,,,��JJ PHONE -Home: (5 %�) �l S CIN: n%r%h J0 ✓� STATE: //(`� ZIP: 0) P `11 PHONE - Work: (5) 397- ��lF JOB SITE ADDRESS (f different): E-mail: Approximate Start Date: / Approximate Completion Date: SPECIFICATIONS Renewal by Andersen approved materials will be furnished and installed to these specifications: 1. Install total of:--L-windows. 2. Quantity of windows: .,._Double Hung (DB) ❑ Equal sash ❑ Cottage sash (1/3 top, 2/3 bottom) ❑ Oriel sash (2/3 top, 113 bottom) _ Casement (CW) ❑ Hinge right ❑ Hinge left (as viewed from exterior): []Standard handle ❑Metro handle _Double Casement (CDW) ❑Standard handle ❑Metro handle _ Casement I Picture I Casement (CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑Standard handle ❑Metro handle _ 2 Lite Gliding Window (GW) _ Glider I Picture / Glider (GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window (AW) _ urr Window ow: ys o+ I' Z : 1 .2 CuP Ba or Bow Window: a 'o ` P""4S 3. � es ❑ No # Windows to be Custom Fit Replacement: 4. ❑ Yes,* No # of sills to be replaced: 5. )1 Yes ❑ No # Windows to be New Construction Full frame (includes new interior & exterior casings): Exterior casings: ❑ Pine $ Maintenance -free material 0 Factory applied 908 Fibrex brickmold 6. Glazing to be: 9 High Performance ❑ Other If other, please specify: 7. Exterior color to be: E9 White ❑ Sand ❑ Canvas ❑ Terratone 8. Interior color to be: 09 White ❑ Sand ❑ Canvas ❑ Terratone ❑ Wood Note: Interior color can only be white, wood or same color as exterior. Wood interiors need to be finished by Gust. 9. Hardware: 'White ❑ Stone ❑ Canvas ❑ Brass Double Hung: Install lifts? ❑ Yes ❑ No 10. ❑ Yes ,Z No' Removal of metal frames or grilles # of Units: 11. ® Yes ❑ No Install new paint -ready or stain -ready casings. Inside or outside stops # of openings: _ Interior casing # of openings: I Exterior casings oyenings: ❑ Pine 11 Maintenance free material 12. Customer aware that RbA does not do any painting. _L Cust. initials 13. ❑ Yes i1 No Wrap exterior casings with aluminum coil stock: color. Note: Required with storm window removal. Removal of storm windows will leave screw holes in casing. 14. New windows to have: ❑ Half or Full screens Screens to be: :ca JkAluminum 15. Windows to have grilles: ❑ Yes QQ No �If Yes: ❑ Grille Between Glass (GBG) ❑ Removable Interior Wood (INTW) ❑ Full Divided Light (FDL) Grille patterns: E E E E Ll DH DH DH DH CW/Picture Glider CSW or GPW use additional sheet if needed Customer approved (initials): _ 16. L79 Yes ❑ No Insulate, caulk and seal windows with three-point system to prevent water and air infiltration. 17. Yes ❑ No Remove and dispose of existing windows and storm 18. Yes ❑ No Clean Up. All job related debris removed. Vacuum nightly. 19. Yes ❑ No Insurance. All workers compensation and liability insurance maintained. 20. E5 Yes ❑ No Warranty. Given to customer upon completion and receipt of full payment. 21. Additional information: 22. Regular Retail Price: $ 23. Total Project Amount: $_�,y 7 All available discounts have been applied: XYes ❑ No 24. Is Project to be paid in 0 Cash ❑ Financed ❑ Combination of Cash and Finance 25. Cash Deposit (1/3): $ 1/3 of balance due at start of job and final 1/3 due)at completion of job. If remaining 2/3 payment ig made by credit card, an additional fee of 3% will be added to cover fee charged by Credit Card 26. ❑ Yes No: Financed. If Yes, Amount Financed: (Account #: ) 27.Yes ❑ No Customer agrees to be present on the final day of installation for final inspection and to deliver final payment. 28. J4Yes ❑ No Homeowner gives RBA approval to place a yard.sion on their lawn at the time of measure. 29. WYeS ❑ No Building Permit - As a convenience the company will secure the building permit. The fee for the permit is not included in the agreement price and a separate check is required at the time of sale for this fee. 'RENEWAL BY ANDERSEN" IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS OR CONDITIONS THAT COULD NOT HAVE BEEN SEEN PRIOR TO OPENING THE WALLS. PLEASE REMOVE ALL SHADES, VERTICALS. BLINDS, CURTAINS, DRAPES OR WINDOW MOUNTED AIR CONDITIONERS, AND ANY FURNITURE AT LEAST SIX FEET AWAY FROM WINDOWS AND DOORS PRIOR TO THE INSTALLATION OF YOUR NEW WINDOWS, INSTALLERS ARE NOT RESPONSIBLE FOR THE REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. 'SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMENT AND'OWNER' REPRESENTS THAT NONE HAVE BEEN MADE TO, OR RELIED UPON BY "OWNER.' YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE OF THIS AGREEMENT. *CONTRACT SUBJECT TO FINAL INSPECTION BY RENEWAL BY ANDERSEN CONSTRUCTION DEPARTMENT. *TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract is a legal document. Your Renewal by Andersen products will be especially made-to-order for you. UNDER NO CIRCUMS�NCES WILL s,reuercnv� .vne wr<ne� r . RbA Rep. Signature: Date: S/�0% T .. 9 Customer Signature: V1J - - Customer Signature: White - Renewal by Andersen Yellow - Installation Pink - Homeowner 02-02.07 The, Commonwealth*ofMassachusetts . ' . Department of Industrial Accidents Office of Invesfigations:. . ' 600 ifWashington'Slreet Boston, M4.02111 www. mgssgov/dia WorkersCompensation-Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (& Address: City/Stat Are you an employer? Check .tbe-appropriate box: 1, am a errlli)oyer with.. 4 ❑ I am a general contractor and I employees .(full and/or.part-func).� 2-. I am a. sole proprietor or partner- have hired the sub -contractors listtd on the attached sheet t Alp: and have no employees .. Thcscsub-contractors have working fol mein any capacity.. workers' comp. inswance- 5. ❑ Wc.arc a corporation sad its . [No workers' comp: insurance required -].officers have. exercised their. I ❑ I am a homeowner. doing all work right of exemption per MGL Thyself (No workers comp.. c. 152, § 1(4), and we have.no insuzanee required.) t employees, [No workers' .•comp- insurance requitedj- . My applicant that ei►e4MU� *1 mnustlalso fill put the section below showing their wotken' compensation policy infoirn"on" HoTmo"cm w1ko.i4rit this affidavit indicating they arc doing sill work and then bits oolsidc eontractari must submit's new:affidii+it indicatiits such ;oniractols that check this box must attached an additional sh"t showing the name ofthe sub-contradors.and.their. workers' entry: policy information, am an employer that is providing workers' compensation insurance for my it res. Below is thi policy andob site rjormrdion. isurance Comlpany Naimc: dlicy'# or Self ins.•Lic. W: 7 p �✓� C �g L i xpirabon Date-_ �b Site. Address; e. City/Statc✓Zip: .ttacb a cyopof the workers' compensation policy declaration page (sbowing the policy, number, and expiration date). allure to secuic coverage as Tequired under Section 25A of MGL c. 132 can lead to'the impositioti of Criminal pest lues of a' nt up to S 1;500.00 and/or one-year imprisonment, as well. as civil penalties in the form of a $TOP V1rORK ORDER and a frac fun to $250.00 a day against the violator. Be advised that a copy.ofthis statcmrnt may be forvva3dod to the Office of " ivostigations of the' DIA fot insurance coverage verification. do hereby ce un r tare di " s' and yenalties Of perjury that the itijormation ptovtded above is true and cot•r���, ' iffiaturc:. OffIciat u$e.Ohly. -Do not write in Xhis area, to be completed by city or rowrr official: Information and Instructions Massachusetts General Laws chapter 152 requires all.employen'tu provide workers' compensation for their employees. Pursuant to, this statute, an employee is defined as. ..... every person in the service of another under any contract of hire, cxpress. or implied.; oral or written," An employer is defined as "an individual, partnership, association, coiporation or other legal entity, or atly t A o .or more. of the foregoing engaged in a joint cn.ttrprise, and including the legal representatives of a deceased employer, or the receiver or trustee of at individual; partnership, association or.other legal entity, employing employees.: However the. owner o.f a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwellinghousc.of another who employs persons to do'matcnance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall.not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or'.' renewal of a licgnse or permit to operate a business or to construct buildings in tbt commonwealth tor.any applicant who has not produced acceptable evidence of compliance witb the insurance coverage required. Additionally; MGL chapter 152, §25C(7.) states "Neither the commonwealth nor any of its political subdivisions shall enter. into any contract for. the performance of public work until acceptable evidence of compliance with the insurance .requirements of this chapter have, been presented to. the contracting authority." Applicants Please fill out the.workers' compensation affidavit completely, by checking the boxes that apply to youi sitilation and, if pecessary, supply sub-contraetor(s) namc(s),'-address(es) and,phone number.(s) along with theircertificates) of insurance. Limited Liability Companies (LLC) err Limited Liability Partnerships (LLP} with no employees othez than the members orpartoers, are notrequiied-to carry workers' eornpcnsation insurance. If an LLC orLLP.does have employees;. a policy is required. Be advised'that this affidavit maybe submitted to the Deparunent.of'Industrial Accidents .for confirmation ofmsurance coverage. Also. be sure'to sign and -date the of davit. - The afl5davit .should be returned to the cityor town thattho application for the'' dmit'orlicense is bcing.requested, not theDeparimcimt.of lndustrial Accidents. ' Should you have any questions regarding the law or if you arcrequired to obtain a woikers' compensation policy; please call the Departrgcat at the number listed below. Self-insured companies should entei thein sclf:insu, ancelicensc numbei on the appropriate line: city 0, Town Olticials Please be sure that the affidavit is comiplete and printed legr�ly. The Department has providcd'a space at the bottom of the affidavit for -you to'fill'outinthe cvenfthe Office of Investigations has to contactyou regarding the applicant Please be.sure to fill in the.pern it/liccnse number which will be -used as a refgccnce number. In addition, an -app- ieant . tbatjnust submit multiple.permit/licensc applications: in any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" theapplicant should write "all locations in'_(city or ���•" . -copy ofthe affidavit that bas been officially stamped or marked by the cityor-townmay be providod to .the applicaAt as. proof that a:validaffidavit is on file .for future permits or licenses. A new affidavit must be, filled out each Ycg- where a.pome owner or citizen is obtaining a license orpermit not reIatcd to any business of commercial ver c dog license or pemi tto'burn, leaves etc.) said person is NOTrequircd to complete this affidavit The Office ofInvcstigations would like to thank you in advance.for your cooperation and should you have any gtscstions, please do not hesitate io give us a.call: ?be DePartinent'.s:address, telephone and- fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600- Washington.Street B ostori, AJA 02111. F tie �o7n�nwmruealt/ a���aavaclusaalta w Jan 02 2007 15:26 JPBMcKeone#ins 734 662 8101 p.2 ACORD. CERTIFICATE OF LIABILITY INSURANCE 0911 PRODUCER Joseph McKeon JP McKeon Insurance Agency, Inc. P.O. Sox 333 Ann Arbor, MI. 48106-0333 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ALTER THEHIS COVERAGCERTIFICATE FFORDED BY THE POLICI STEND BELOW. INSURERS AFFORDING COVERAGE wuC ' INSMIRED Renewal by Anderson J&L Windows, Inc. 104 Otis St . Northborough, MA 01532 INSURER A: Hartford Insurance n INSURERS: INSURER C: INSURER n: IN6URER E: COVERAGES x THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW, MSR ADDI POLICY NUMBER. POLICYEFFECTIVE POLICYEXPIRATIONmm DAM IW=NY1 UNITS HER8858850 .917!06 9/7/07 EACHoocURRENCE $ 1,000,000 B GENERALLIABLITY PREMISES a omurence i 100,000 COMMERCIAL GENERAL-"ILITY CW MS MADE © OCCUR MED EXP one' on i 10.0w PERSONAL a ADV INJURY i 1 .000,000 GENERAL AGGREGATE $ 200,000 GEN'L AGGREGATE LIMB APPLIES PER PRODUCTS . COMPIDP AGG $ 2,000,000 POLICY PRO-JECT LOC A AUTOMOBILELIABEITY ANY AUTO 35 MCC XD 6388 1011/05 10/1107 COMBINEDSINOLEIJWT = 1,000,000 (EA weldenl) BODILY INJURY i (Per Pe-) X ALLOWNEDAUTOS SCHEDULED AUTOS BODILY INJURY i (Per eecktbnt) HIRED AUTDS NON•OWNEDAUTOS PROPERTY CWAAGE i (Per ecdAe nt) GARApELUABIL" AUTO ONLY -EA ACCIDENT i OTHERTHAN EAACC i ANY AUTO AUTO ONLY: AGG i EXCESSIUMBRELIALIABILITY EACHOCCURRENCE S OCCUR FICLAIMS MAIC AGGREGATE i i $ DEMTW f RETENTION S A WORKEnecaMlIWMT1OXAND 35 WBGNC8861 1/1107 1/1108 X &STATI' OER EMPLOYM LIABILITY ANY PROPRIETORIPARTNER/EXrCUTIVE E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYEE S 5=000 OFFICEWMEMBER EXCUX ED? ITee elNorbe uriaer 8 IAL PROVSIONS below E.L DISEASE- POLICYLIMfT . i500,000 OTHER DESCRIPTION OF OPERATDNS I LOCATIONS (VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ULK1 ENSURED COPY SKOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE DMRATION DATE THEREOF, THE ISSUING BMSIAER WILL ENDEAVOR TO MNL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMID TO THE LEFT, BUT FAILURE TO DO SD SHALL IMPWL,NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE PMREII, ITS AGENTS OR ACORD 26 (2001108) ` / \ CACORDQRPARATION 1988 Design Pressure (P$F) MtnlfrarrtlArialM . - ti••yI.FdlnlFprt C- R 3 O i rW.ie Ar Irt1M; tao•eo M eolua-ooh Ia*+laot ' ! Iwr••tvn• rdlyl•N• .•11•rHnd c� N'• N111.r11. rt•rltrlr. Triol t. �MII/MIM/Ielp( t11/Z•d1��7 Meds or exceeds M.E.. G.,4f-C., b I.FC.C_ Air In116Mn Re40Irements WOM4 HIIlmalk Certlric4tlon Program i I 1. i i i f i i- t 1 - ' - Design Pressure (P$F) MtnlfrarrtlArialM . - ti••yI.FdlnlFprt C- R 3 O i rW.ie Ar Irt1M; tao•eo M eolua-ooh Ia*+laot ' ! Iwr••tvn• rdlyl•N• .•11•rHnd c� N'• N111.r11. rt•rltrlr. Triol t. �MII/MIM/Ielp( t11/Z•d1��7 Meds or exceeds M.E.. G.,4f-C., b I.FC.C_ Air In116Mn Re40Irements WOM4 HIIlmalk Certlric4tlon Program This certifies that Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING . ......... 4 ............. I ........ �d ................................ . ... ............. . ..... A Jl/m 1 "iz7 has permission to perform ........... ........................................... wiring in the building of AM,( IA.A�.:564V ........ �**...� ............ 0 at..,.... ... .. A ...... ...... ....... i ................... . North Andover, Mass. Fee...... ............. Lic. No—y ... ELEmicAL INspEcrOR Check # q 1-1 "'54 5 0 "? Commonwealth of Massachusefts 5: Department of Fire Seces BOARD OF FIRE PREVENTION R GULATIONS APPLICATION FOR PERI All work to be performed in accordance (PLEASE PRINT IN INK OR TYPE A City or Town of: _g By this application the undersigned gives Location (Street & Number) Owner or Tenant A / _ I Owner's Address Official Use,Only Permit No. Occupancy and Fee Checked [Rev. 1 l/99] leaveblank Iii' TO PERFORM ELECTRICAL WORK Orth the Massachusetts Electrical Code (MEC), 527 CMR 12.00 TATION) Date: ,// —3 Q -• c q 11041;51 4 To the Inspector of Wires: or her intention to perform the electrical work described below. 2L 9 9 9e 7' Z _�% fy) ,S Y r Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No./ Z/-7 Existing Service o Ampsf� 0/ aG/`olts Overhead Undrd g ❑ 'No' Meters � �— [ . New Service ') 00 Amps /j -o Volts Overhead Q'' Und d gr ❑ No. of Meters Co Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r'mmplolinn of Iho fnlln.erino MAI. — A. v,n;,-.d A.. iA- r» ... ,,r,...-,rri1:-.._ No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑In- E] grnd. grnd. No. ot Emergency Lighting Batten Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No: of Zones No. of Switches No. of Gas Burners o. oDetection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I.Number Totals: I Tons I KW I No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of ]tires. 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 s in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Estimated Value of Work to Start:_ I certify, under FIRM NAME: Licensee: VziA J 14 -e ni (If applicable, enter "exempt' in the Address: DLCO �✓� 5` OWNER'S IM required by law. Owner/Agent Signature _ C / ®!? (When required by municipal policy.) (Expiration Date) Inspections to beiequested in accordance with MEC Rule 10, and upon completion. ilties ofperjury, that the information on this application is true and complete LIC. NO.: i ignature C. NO.F -3. C xnse number lin �,A 461 Bus. Tel No .Pf iR `73t5-b<3i VVI l �4 y Alt. Tel. No.: 9 5 q F� S l b J1c1k1vl:P: wAtvER: I am aware that the Licensee does not have the liabty insurance coverage normally By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Telephone No. PERMIT FEE. $ 3184 Date. -.� -,2 - �� -- :� 5 ...... ORTN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATIONK This certifies that 5:'-ve�f ................... M. has permission for gas installation .... ........... V in the buildings of . . ........ at ..,2 -� - .0f., r. --� - - f -( .......... North Andover, Mag. Fee.,).�),.-... Lic. No..�7.�2..? ASINSPECTOR WHITE: Applicant CANARY: Building D:t. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 2 G (Print or T e) d^ , Mass. Date 19Permit # //JJ Building Location Owner's Nam. /a A41era-&Zln25�L� 4& Type of Occupancy1-3 E51 -DCN T i P G 0 New ❑ Renovation ❑ Replacement 2-11' Plans Submitted: Yes[] No ❑ Installing Company Name r, AE jZ � :� Ain MA T r) Check one: Certificate Address 30 0oA c N m A ry 4-kf. . ❑ Corporation Al E 7 N U e fJ 01 rl 0 (k ❑ Partnership Business Telephone 15, 92 -2 9 "7 f 2-'Firm/Co. Name of Licensed Plumber or Gas Fitter "( Qjj F- P- T A • 5 A M M t1 T A 1?(D INSURANCE COVERAGE: I have a current pf billy insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes W' No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe i ed for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. By T of License: C� Plumber n ure o Licensedu or Fitter Title tter 133 er Ucense Number City/Tovm I Journeyman . Y 1 .. ■!!!!!!!!!!!!!!!!!!!!SENSE .. !!!!!!!!!!!!!!!!!!=Emmons MR MW Installing Company Name r, AE jZ � :� Ain MA T r) Check one: Certificate Address 30 0oA c N m A ry 4-kf. . ❑ Corporation Al E 7 N U e fJ 01 rl 0 (k ❑ Partnership Business Telephone 15, 92 -2 9 "7 f 2-'Firm/Co. Name of Licensed Plumber or Gas Fitter "( Qjj F- P- T A • 5 A M M t1 T A 1?(D INSURANCE COVERAGE: I have a current pf billy insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes W' No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe i ed for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. By T of License: C� Plumber n ure o Licensedu or Fitter Title tter 133 er Ucense Number City/Tovm I Journeyman 0 % W a Z N _Z N V N W r Q Q d O — crICL, Z N O Z h H V W r Q N — Z N df } Q J � - = O O G W O h W L7 � ¢ O Z ¢ ¢ J Z O IL O in J GU. m JO W < d C m t1 } d IL - F W � Z J LL O h V W Q N Z df