HomeMy WebLinkAboutMiscellaneous - 125 Main Street o D �
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NORTH ANDOVER BUR-DING DEPARTMENT
�RSTt.US LF5OK c5 1600 Osgood Street
s$ACf9
North Andover .
Tel: 978-688-9545
Fax: 978-688••9542
B?T,S `S',S`FORM., OR TOHZ CLER
DATP-
NAME:
ADDRESS;
Z® TG.DISTRIC :
TYM WBUSINES : r° r �dm
BUILDING LAYOUT PROVIDED:
A.VAILABLEPARKMG SPAM:
ZOWNGBYLAVAUSA.GE: YES NO
E S CTO .SIGNATUPIE
RUSMSS FORM FORTOWN CLERK
3
2.4o Home Occupation(1989132)
An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal
address, which is clearly secondmy'to the use'of the-building for living purposes. Home occupations shall
'include,-blit riot'limited to the following uses; personal services such as fmn shed by an artist or instructor,
but not occupation involved with motor vehicle repairs, beauty,parlors, animal kennels, or the conduct of
retail business,or the manufacturing o£goods,which impacts the residential nature of the neighborhood,
4. For use of a dwelling in any residential district or multi-family district for a home occupation,the
following conditions shall apply.
a. Not more.than a total of three (3) people may be employed in the home occupation, one of
whom shall be fhG-ow.uer of thd home occupation and residing in said dwelling;
b. The use is carried on strictly withinthe,principal building;
c. There shall be no exterior alterations, accessory buildings, or display which are not custommy
with residential buildings; .
d. Not more thm twenty-five(25) percent of the existing gross Poor area of;the dweEng unit.
so used, not to exceed one thousand (1000) square feet; is devoted to'such use. 7n
connection.with
such use,there is to be kept no stock in trade, commodities or products which occup r space
beyond these limits;
e. There willl be no display ofgoads or wares visible from the street;
f The building or premises occupied shall not be rendered objectionable or detrimental to the
residential character of the neighborhood due to the exterior appearance, emissiozi of odor,
gas, smoke, dust, noise, disturbano% or in any other way become objectionable or
detrimental to any residential use within the neighborhood;
g. Any such building shall include no features of design not cust6niary m buildings for residential
Signature Date
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► MMTM '
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�ACNUL�
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 678-2011 Date: June 3, 2011
THIS CERTIFIES THAT
THE BUILDING LOCATED ON Maya Salon, Unit 41., 125 Main Street,
North Andover, MA 01845
Hadi Fares,
MAY BE OCCUPIED AS beauty salon IN ACCORDANCE WITH THE PROVISIONS OF
THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS
MAY APPLY.
Certificate.Issued to: San Lou Realty Trust
125 Main Street
North Andover,MA 01845
Building Inspector
Fee: 100.00
Receipt: 24215
on
�+uxut�
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 678-2011 Date: June 3, 2011
THIS CERTIFIES THAT
THE BUILDING LOCATED ON_ Maya Salon, Unit #1, 125 Main Street
North Andover, MA 01845
Hadi Fares,
MAY BE OCCUPIED AS beauty salon IN ACCORDANCE WITH THE PROVISIONS OF
THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS
MAY APPLY.
Certificate.Issued to: San Lou Realty Trust
125 Main Street
North Andover,MA 01845
Building Inspector
Fee: 100.00
Receipt: 24215
5
ATTENTION
To sterilize implements,use one part bleach to ten parts
Fold,Then Detach Along All Perforations water(e.g.,four ounces bleach to forty ounces water;
-t any stronger could rust metal implements).The method
used is as follows:Rinse the implement in water first,
ICOM.MONWEALTH OF MAS�A�HUSETTS: then immerse the implement in the bleach solution,shake
s o • - si • the implement in the bleach solution,repeat the rinse/
BOARD flt3ARf1'f)i= immerse/shake process described,rinse the implement in
water a final time then wipe the implement dry with a
HD COSMETOLOGISTS II clean cloth or paper towel.A hair dryer may be used to
I ensure the metal implements are dry and less apt to rust.
I S S U E S THE FOL L OW)NG `L I C E N S E W place in a closed cabinet or disinfectant solution.This
acprocedure applies to plastic,metal,steel,or rubber.
AS A k!A I'R RESSER/CE#SMETOLOG t'ST 1 3 This is the recommended infection control procedure
TYPE of the Centers for Disease Control regarding all blood/
pathogens, including HIV infection/AIDS.
—1 HAU 1 E FARES f prohibited gbA MAss98).Prices
Gender based pricing is pro PUBLIC
ACCOMODATIONs ACT(GL C. S 2 AND
must be based on factors such as hair Length or
5g
0 N BROADWAY W difficulty of styling.
970597 441V E RA ILL MA 01832 1505
1 124702' 0'x/34/'1::7
1 Fold,1 hen Detach Afong All PerforationsIUSA
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Date. .
8914
TOWN OF NORTH ANDOVER .
p PERMIT FOR PLUMBING
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10
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This certifies that . . & . . . . . . . . . . . . . . .
has permission to perform . . �(� £,.tic:?. . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of
jt✓S. . . . . . . . . . . . .
at . . . . . . . . . . . .. North Andover, Mass.
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Fee.1 UU.Lic. No...2,�'X q . . l�l� . .,! . . . . . . .
PLUMBING INSPECTOR
Check "
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: �,'02f/--r /-}OD15V9R, MA. Date:—'05-- / t — Permit#
a
Building Location: 1,�S /I'll t AJ S% Owners Name:_ /414 D/ F14POEZ S
Type of Occupancy: Commercial
❑ Educational❑ Industrial❑ Institutional❑ Residential❑
New:❑ Alteration:❑ Renovation:❑ Replacement:❑ Plans Submitted: Yes❑ No❑
FIXTURES
DEDICATED
LU z SYSTEMS
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-SUB BSMT.
BASEMENT
15T FLOOR I
2ND FLOOR
3RD FLOOR
4T"FLOOR
ST"FLOOR
6T"FLOOR
7T"FLOOR
BT"FLOOR
�� Z � l Pv 11 1� t AJ Cr Check One Only Certificate#
InstallingJCo/Impany Name:
/ l7 �/g/t1j�0 Rq2O Q6- �. � M ./1,
El Corporation
Address:
City/Town: CT l N tate: yT
❑
Partnership
Business Tel:-9
1S 9r`f Ll3os� Fax:
❑Firm/Company
Name of Licensed Plumber: 20 D r 12 f 9(/9 L(')�N
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑
If you have checked Yes,please indicate the.type of coverage by checking the appropriate box below.
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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owners Agent Owner El Agent E]
1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the nor Laws.
By
Type of License:
Title lumber Signature Licensed Plumber
City/Town ❑Master
O
E
APPROVD OFFICE USE ONLY ❑Journe man License Number:
1
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 tino6 of,pn5Ding 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 progresses'duringtimEpreceding 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.
le 8—Permit/Date Closed: Note:Reapply for new permit^
❑Permit Extension Act—Permit/Date Closed: ,se
10021
Date,/ .////.............
NORTF�
'�"°°� TOWN OF NORTH ANDOVER !
PERMIT FOR WIRING j
••.T.D
;�Ss�cMusE�
This certifies that .....- .u s 1.
has permission to perform .... .. .................................. .............................
wiring in the building of
........... .....................................
u at...f a. .....j'►'! lh.... ��.-....... &A1 I—...� orth Andover,
Fee.A�........... Lic.No...... .U 0.5-.k. ......... .�„t ....�. _
EL cv.INSPECro a
Check # -���
l .
Commonwealth of Massachusetts
Official Use Only
Department of Fire Services
FPermito.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Inspector 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 Tenant ,G W jj , �,t� Q,� Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service SOD AmpsVolts 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: �" h
1 I�nlrP� .
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Cell: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- o.o mergency ig tingrnd. rnd. ❑ 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
Initiatin Devices
No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW.......... No.of Self-Contained
Totals: Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances Key Security Systems:*
No.of WaterNo.of No.of Devices or E uivalent
Heaters No.of
KW Data Wiring:
Si ns Ballasts
No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin
OTHER: g:
No.of Devices or E uivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (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 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,tinder the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: O e LIC.NO.:
Licensee: 56
�n T1 �rwc� 12 Signature C.NO.:
(Ifapplicable, enter "exempt"in the license numberTine)
Address: Bus.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt 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. $
ELECTRICAL PER1Vl.IT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR-DOUG SMALL
Y.ROUGH INSPECTION:
Passed— Failed—[ ] Re-inspection required-($50.00)-[ ]
Inspectors'comments:
(Inspe ors'Signa e-no' itials) ate
2.FINAL INSPECTION;
Passed—[ ] Failed_r .7 Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials)
- Date
3.UNDER-GROUND INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials)
Date
4.INSPECTION—SERVICE:
DATE CALLED NATIONAL GRID: NAS,
Passed—[ ] Failed—[ j Re-inspection required($50.00)
Inspectors' comments:
(Inspectors'Signature-no initials)
Date
5.INSPECTION-OTHER:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(inspectors'Signature-no initials)
Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A.RE-INSPECTION OF$50.00 IS TO BE CHARGED.
'4.
x The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,AM 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: 1&1/ Gp4,K1eGG )2b
City/State/Zip: -7?Phone #: q91 D Gr_ dj 2
Are you an employer?Check the appropriate box:
1.El Type of project(required):I am a employer with 4. ❑ I am a general contractor and I Type of
construction
employees(full and/or part-time).* have hired the sub-contractors 6.
2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
ti [No workers' comp.insurance 5• ❑ We ate a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I 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.]f 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.
f 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: 1
Policy#or Self-ins.Lic.#: Expiration Date:
V
r.� L
Job Site Address:—\ 1 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 certify under the pa' s and penalties of perjury that the information provided above is true and correct.
Si nature: Date: �r
Phone#:
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 M
i
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to 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,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,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 license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with 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 1 to your situation and,if y
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy;please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant "
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
Location �G'�r �2 3
No.
NORTH TOWN OF NORTH ANDOVER
a i �
Certificate of Occupancy $
• "a a
CNU
< Building/Frame Permit Fee $
st Building
/Frame
Permit Fee $
Other Permit Fee $ 3
TOTAL $
Check #
24 ► 5 "I
Building Inspector
µORTH..
O� t�ao rs
3? - ty„mssa G�
°, M TOWN OF NORTH ANDOVER
SIGN PERIlliIT
SwCHt1.`-+�
DATE: May 12, 2011
PERMIT: S038-2011'
THIS CERTIFIES THAT Hadi Fares, #978866-622.7 �P� �c�s�n/� Q-7k-j'6 6 — 6, 2 17
Has permission to erect wall sign 22"x8” Salon Maya
on 109=1123 Main Street North Andover MA 01845
provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this
office,, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover.
Violation of the Zoning of Sign Regulations, Sections#6, Voids this Permit.
INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED
Receipt 24151 Inspector of Buildings
Paid: 301.00
SIGN PERMIT APP LR CATff(DIST
1600 Osgood Street Building 20,Suite 2-36
TOWN OF NORTH ANDOVER Date: � ' l�'•Zo�/
Name of applicant who is purchasing the sign
Site Owner _Sigh/-ZO4 leef,4Z-7' �. o/
Phone#of applicant who is purchasing the sign � �0 CD � �z z 2
Site Address ie— / S Name of sign company ( 7 f �E ��j6
Phone#
Parcel Size of Proposed Sign X 2 Z
How attached: a)Against the wall Illumination: a)Not illuminated
b)Roof b)Internally illuminated
c)Ground
c)Externally illuminated
d)Other Materials:
Proposed Colors: Background
Lettering
Border Cost of Sign
)IReguired Attachments: 1`�IOtte: No permanent/temporary or
Photographs of building p p ary sign shall be erected,or enlarged until an
Material sample application on the appropriate form furnished by the Sign Office has been filed
Color sample with the Sign Officer containing such information including photographs,plans
and scale drawings,as he may require,and a permit for such erection,alteration,
Site or Plot Plan(Required for.all free-standing signs) or enlargement has been issued by him. Such permit shall be issued only of the
Drawings of proposed sign Sign Officer determines that the sign complies or will comply with all
Other,specify applicable provisions of the By-Law.
Will sign overhang any public road or walkway Yes( ) No( }
If Yes,Name of Agency who will provide liability insurance:
AN INC E APPLICA I I®N VVIf ,NO I'DE ACCE 'TED
DATE]FILED:
Receipt# Check#
Revised 10.31.2006Form Sign Permit Application 4;Ml
T APPROVED
Sign is 2211 9
N Cornp�ry: Sam MAYA File:
MIV and can not be mwap oducedwtthautthe
24 Spencer Shuet Soneham+DILA Apwovuk pa"= GamltSim.
j FAX CMI -ate
Date....../..�..
HORTM
°!t"`°;•�"° TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
s '-o•�no•A� (y#
ACNUSE�
This certifies that 7;; ..13e7-
. E�TJ1,C
.......... ............................. ................................
has permission to perform .�Tv
...............................................................................
wiring in the building of....-��'!1! L.4. "F1�7`'I!..%�4T................
....... . ............
at..I 25 M'Oli:1!!...5.�.... ...........0 '�..!a ..... . ,North Andover,Mass.
Fee... Lic.No.I. .�,'�.,�................ <1.......
ELECTRICAL INSPECTOR
Check 'I ���
8359
,F e.
Y:' • Commonwealth of Massachusetts Official Use Only �1
Department of Fire Services Permit No. t� 10
' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: —12—op
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) IAJ57- Ba
Owner or Tenant t� L p t 32,Q t4 (}'yl 7 ku CT Telephone No. 9
Owner's Address 0-5- M/ti.J UA)it- 19 Z Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building,�i J5 4(f— 1 lO7 Utility Authorization No.
Existing Service 16LAO Amps 17 D /20 sr Volts Overhead ❑ Undgrd,M No.of Meters f0
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: �� & CJN i TS•
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-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- ❑ o.o Emergency Lighting
rnd. rnd. 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
InitiatingDevices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number .Tons K .....WNo.of Self-Contained
Totals: Detection/Alertin2 Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water KW D
No.of No.of No.of Devices or Equivalent
Data Wiring:
Heaters Signs Ballasts No.of Devices or Equi alent
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 Wires.
Estimated Value of Electrical Work: /SU,e60. (When required by municipal policy.)
Work to Start: /2_d 1r 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 in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:)Obe '19'9'
I certify,under the aims and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO...,J�ZVS1--
Licensee: te!!/N j� G/�OT Signature LIC.NO.:
(If applicable,enter- empt"in the license number line.) Bus.Tel.No.:
Address: �� A«S �z ST S'r9&,wf SAW, Q/976 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
Signature Telephone No. PERMIT FEE. $` _
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Office of Investigations
i
UT 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): � � `�
Address: leo
.1
City/State/Zip:!/1&". ,ad 01 9?6 Phone #:
JAre you an employer?Check the appropriate Brox: Type of project(required):
R I am a employer with A2 _ 4. ❑ I am a general contractor and I 6• ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. # 7• ;N 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 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per'MGL 11.[1 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'
comp. insurance required.] 13.0 Other
*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 hue 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: .5
Job Site Address-/2Z-5_ City/State/Zip: O;V//(/Z'/L %
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 cern under the pad alties of perjury that the information provided above is true
and correct
Si ature Date: O
Phone#:
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#•