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HomeMy WebLinkAboutMiscellaneous - 127 VEST WAY 4/30/2018Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. vv� � �� r rvr irrCAltl 1 vl IVIQr1�Qtr11U,C111 City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health; .Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The Systim Pumping Record must be submitted to the local Board of Health or other approving authority within 44 days from the pumping date in accordance with 310 CMR 15.351, A. Facility Information �o System Location: v C -J f WA,/ N21A.,00VEC City/rown state Zip code 2. System Owner. Name nen Address (if different from location) City/Town state ' Zip Code 7Tk %D(r' O Telephone Number B. Pumping Record 1. Date of Pumping � P g _ Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ID -Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: �I'Wt , Name Vehicle License Number C30�'<�c' z� k Seal'►�� Company 7. Location where contents were disposed: (cW ja- 4�2 - Sig re --03 Hauler Signature of Receiving Facility Date Date t5form4.doa 03106 System Pumping Record • Page t of 1 � Commonwealth of Massachusetts City/Town of R 15 System Pumping Record JAN 1 1 2g1� Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of HealtR but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The Systgrn Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information bhe-k o�oLjSe neY4 c r Important: When /sjry� yh CU r'r e t G �' �uM' 6 u filling out forms 1. System Location: Gil w�/I I , on the computer, nt�� ��� ) n j� use only the tab / y 61A key to move your Address cursor - do not A/h�Uye-r �� use the reiurn Cit /Town key. y State Zip Code VQ 2. System Owner: 11 1( r"6L�rV 0 Name — ieem Address (if different from location) City/Town B. Pumping Record State Zip Code 7V- -7o6- O�7T Telephone Number 1. Date of Pumping Date 11-30-1( 13o—I( 2. Quantity Pumped: Ga/5ons-00 -- 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: e, 1"///0 U17 aG,C 6. System Pumped By: Name _ Company 7. Location where contents were disposed: ISD K'easy P Signature of Hauler Signature of Receiving Facility Vehicle License Number Date Date t5form4.doc- 03/06 System Pumping Record •Page 1 of 1 N° �l � i �l Date .... ✓. / ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........:.. ................................ :........................................... has permission to perform ..... -,:....... !..:,.r:.: �......��..�..�.� �..:.: Z- .................. wiring in the building of .................................................. tat ..... z '.J.........,.. f:.:. ......\:..! .(�'..:L...................... .. 6rth Andover, Mass \ \ .�'. % � 7.1.......... t .....: ..� .. i (..:..�. Lic. No... .: / Fee... ... .... ........ ..... ELECTRICAL INSPECTOR 08/10/99 14:43I A 75.00 PAD WHITE: Applicant CANARY: Building Dep . PINK: Treasurer VPP =(19A MONWEALTHOFMA.SS4GIV E77S Ofce Use oniv DEPAR.'ji�EVTOFPUBLDC�TY Permit No. BO* OFFDXEPREVEMOIVREGUL4TIONS527CMR 12.00 Occupancy & Fees Checked �����ANCE`TO PERFORM ELECTRICAL, WORK THE MASSACHUSSTS ELECTR &II CODE, 527 CMR 12:00 (PLEASE PRLN i 1N INK OR TYPE ALL I`NFORMATI0N) MAP Town of North Andover '—'fit e Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. PARCEL Location (Street & ;`lumber) Ao � ��� � 4 �� Owne- or Tenant 0 %I -/U Owners address 1 7 Is this permit in conjunction with a building permit: Yes Purpose of Building No (Check Appropriate Box) Utility Authorization No. GDi 3.Zs` Existing Service t2av Amps 120 /&0' V0(ts New Service 1,V Amps /W/2/UVolts Number of Feeders and Ampaciry Location and Nature of Proposed Electrical Work No. of Meters No. of'vleters No or`�ighting Outlets No. of Hot Tubs No. of Transformers Total KVA No of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 0 eround No. of Receptaue Outlets No. of Oii Bumers No. of Emergency Lighting Battery Units No of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No of Ranges I No. of Air Cond, Total Tons No. of Dc,cc,;on and No of [) r o .• ?ic.' of `J .: Total Tctn: Pumos Tons Kw fnniating Devices No. of Sounding Devices i No of Dishs.asie;s Space Area Heating KW No. of Self Contained -� Detection/Sounding Devices Local Municipal � Connections Other No of DrJers Heating Devices KW g 10 of'Tate. Heaters KW No. of No. of Signs Bailasis �eirvero .`lassage Tues No. of Motors Total HP I " 4�• 1 �� .� •' �♦ 1 •, 111 •' • :1'i!' � � •1• • • i •L- • ,\ ` /J �' :191 i•: f ` •• Illi • • •••' " " '• i � 11 •" � - •� � • • i1 i• w •'i:C' 1 11 K.: 1 ' 0-3 1111 Wcd iDStart i Sered is E Pa�aities J V, H• /: Eso iwdValuecfEl2m---J Wci1 S Ragh Final 1'--r5e.ND �Z _ �- Bts�esTei Na �f % �25� QS(o OWNER'S iN�.,R�,� 1V. • I a; i aua� tt�r� Lim �Oes rrt twre tip r<�rar� me:. � a -a stf�raxil �rvala� as t�.m-a�i b�, lv�;x�5 C�>e� ia�s aa'ti�,-rn's�ttsern it's p�nlirt ,�� �s t>t�it 1 (Please check one) Owner, a Agent Telephone No. PER'AiT FEES ..-_...a.... _ .._. ,., .... - _ ....,..- ^f t .. R o��. � �U�1� � t /J .� C J eJ�w�-cam p�-�"�� �ry���-v�-� � �if���l,� ���� � � � - f�y� �.� s� �� � 1 11 Date ... n. .- @L. 5 -. 0.7 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... baA I M ... I .................... ........ has permission for gas installation . . i in the buildings of ... t, I x. 0 .................................. -4 at ... ! . L.� ..... 0 T , .� ...... North Aqdover, Mass. Fee. 4.9 .... Lic. NoIOA... ..T-. 7 GAS INSPECT,, R Check# Q too 4001 (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations j Z-7 VC Sri &J/I I- C, %14 - C,%14 Ow New ❑ Renovation 001� Replacement PERNIlT TO DO GAS FErMG Date %/2,1/0 y G r -- Permit # r Amount $ Name �z�1�Jq �r9-/Z.�,�p Plans Submitted ❑ (Print or type) Chec one: Certificate Installing Company Name �-v l�C 141 P) L.0 A, 6 J � U 11 Corp Address 630�-�'J S e"o �'L v L.r✓ Partner. Business Telephone & ( 7 E. 66 7-777,7 El Firm/Co. + Name of Licensed Plumber or Gas Fitter 3T't° j9 Z-c� 7 7v I INSURANCE COVERAGE Check one: . I have a current liability Insurance policy or it's substantial equivalent. Yes � NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy lzr Other type of indemnity 13 Bond 1 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 0 Agent 0— 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. 1 By Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licens Plumber Or Gas itte Plumber a l Gas Fitterense NuMber Master — _ 9/3 0 Journeyman w wrA v� W a rA U o a x 1.1 z (A rA aW 90 UP) a o o z w z� `� ° z o a' 3 A z� o W A o 11 a w U0 a° a H o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Chec one: Certificate Installing Company Name �-v l�C 141 P) L.0 A, 6 J � U 11 Corp Address 630�-�'J S e"o �'L v L.r✓ Partner. Business Telephone & ( 7 E. 66 7-777,7 El Firm/Co. + Name of Licensed Plumber or Gas Fitter 3T't° j9 Z-c� 7 7v I INSURANCE COVERAGE Check one: . I have a current liability Insurance policy or it's substantial equivalent. Yes � NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy lzr Other type of indemnity 13 Bond 1 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 0 Agent 0— 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. 1 By Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licens Plumber Or Gas itte Plumber a l Gas Fitterense NuMber Master — _ 9/3 0 Journeyman � Date..?. TOWN OF NORTH ANDOVER < a p PERMIT FOR PLUMBING This certifies that 4 � C. � t �, t � u �!'i ........... has permission to perform ..��! ... lC t'�! !r..�................ . plumbing in the buildings of .................. �. .. S� W A , North Andover, Mass. at..r...... �..... )A Feel .�Lic. No. I3.`... .' � 1 O..... /M! c '...` PLUMBING I SPECTOR ti Check # t f MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, .M/ASSACHUSETTS Building Location I ZI V fid i L.1`I Ow Vof--T/i�a vrL Type of New Renovation Replace. CATION FOR PERMIT TO DO PLUMBIN FIXTURES Plans Submitted Yes Date ?�� 1 A(Y Permit # Amount S oZ No El (Print or type) Check one: Certificate Installing Company Name PL -C-141 fj '> r%N tj ri Corp. Address 50 (>vt7_0 D �T � c rt crcV / iL. IQ ❑ Partner. Business Telephone 17 <oG % IL Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the _type of insurance coverage by checking the appropriate box: Liability insurance policy © Other type of indemnity 0 Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner 11 Agent rl 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 Permit Issued for this application will be in compliance with all pertinent provisions of the M"achusetts Sta� Pl bingyod!3,anq Chapter 142 of the General Laws. y: OVED (OFFICE USE ONLY - Type of Plumbing License icense Number Master El Journeyman 0 -n Date ... ��� ev .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....' . /...:; ... f... ... .... ....................... ..... /'c . =-z.-e-�i 1�,,ac�..-v'��--fit has permission to perform .......... ..................:......... �...:................................ wiring in the building of . ��`'"'�1 `�;'y....................................................... � .,.v` v ,,,N rth Andover, Mass. Fee..................... Lic. No.............., ...........................G. -..................... �� � ELECTRICAL INSPECTOR Check # ---��! — r,771 THE COMMONWEALTH OF MM SSACHUSETI S DEPARMEWOFP(IBIICS MY tBOAROOFFIREPREVEMONREGUTA77ONS527QNR12-00 Office Use only Permit No. S3-71 Occupancy & Fees Checked �S APPLICATION FOR PERMIT TO PERFORMELEC'FRICAL WO 73 L-1 ALL WORK TO E PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK O TYPE ALL INFORMATION) Date2, Town of NortA Andover To t Inspec or of Wires: The undersignegapplies or a permit to perform the electrical work described below. Location (Street & Num er) / 2, �2 i 0 7a v Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ® No (Check Appropriate Box) Purpose of Building TO e, t Utility Authorization No. Existing Service Amps/ D/ LVdVolts Overhead Underground a No. of Meters New Service AmpsVolts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work _O1 A_Q1 p P % A -,)i C X &, J4 r,V 8 1AM No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures // Swimming Pool Above Below ri Generators KVA I ground round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal ID Connections Other No. of Dryers / Heating Devices KW No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP f OTHER• `� Ir>StaanaeCo�erag� Ptisi�anttatheleqtmarlenlsof�etlsGalaalLaws IhareaamatliabklmrmmP hyincktdalgCorTi CoNeWorgsmbfrtialegrmiErt YES NO Ihavesibniwdva5dpoofofswlebthe01 m YESIf)mhawdtedWYESea9eilldcateth ,pleNxofwuWby (�i� box INSURANCE BOND MIER Few**) VakiedElochicalWodc $ WW ODStad kWectionD,*Regi *d Rao 00±2 Furl FIRMNAME � k'► 1 r— Lkmsx 49n �P G,eG t-` Sigrwle IjL�1�l�lp BusimTelNo. n AIL Td No. OWNER'SINSURANCEWAIVER;IamawmdrtdrLio wdoesmthavetheinslmmcoNeageaitsa*sUtaleq vuialasmgiaadbyMa%aduc,mC xdLaws "drtmysignahneonftpeant*pbcabmwa'mtliSm melnt (Please check one) Owner 1:3 Agent dL Telephone No. PERMIT FEE signature of Owner or Agent M Location No. Date a b TOWN OF NORTH ANDOVER n Certificate of Occupancy $ s•," E�� Building/Frame Permit Fee $ O� Mus Foundation Permit Fee $ Other Permit Fee $ '— TOTAL $ n t Check # *-% '10A (C,,- 17 416 Building Inspector Location &-7 No. I k 9, Date 4 xo K a TOWN OF NORTH ANDOVER Certificate of Occupancy $ ` Building/Frame Permit Fee $ Foundation Permit Fee $ 1�3 Other Permit Fee $ v7 Sewer Connection Fee $ Water Connection Fee $ TOTAL - �- / Building Inspector niv Puhlic Wnrkc Location No. ��_ Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ r J' Building/Frame Permit Fee $ Foundation Permit Fee $ T.= U , Other Permit Fee $ w Sewer Connection Fee $ Water Connection Fee $ -------- TOTAL .r Building Inspector Div. Public Works TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 7 Set" for BUILDING PERMIT NUMBER: n DATE ISSUED: a SIGNATURE: Building Commissioner/122Mtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel lip Map Number Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) Public 0 Private 0 Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System 0 SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 111 a LU r i U u i s u i LA. r U 5 _IN U 2.1 Owner of Record �os��l� i'hx}2�aa 127 /4S7 - Name (P 'nt) Address for Service Signa re Telephone 2.2 Owner of Record: r + Name Print Address for Service: r Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 17%%s7 License Number Add ess //,O� z cy;,t., 6011^6-05-17 Expiration Date Sig&urc Telephone 3.j Registered Home Improvement Contractor Not Applicable ❑ I Compt�cName Ak • Registration Number Address Expiration Date Signature Telephone r' SECTION 4 - WORKERS COMPENSATION (XG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: /�C•'�2P f-lr— �Z/ rc-h f'J iNt I SECTION 6 - FSTTMATF,D rONCTRiTrTTON rncTc 1 Item Estimated Cost (Dollar) to be Completed b permit applicant OFFICIAL USE ONLY 1. Building dam (a) Building Permit Fee Multiplier 2 Electrical b deo (b) Estimated Total Cost of Construction 3 Plumbing Z- Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 D v a v Check Number Ar.l.11vt`I is UW1'4ZX AU JLnUK1LA11U1N 1U fit UUMNLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT !— P4 f71 /9-21 N o as Oxvner/Authorized Agent of subject property Hereby authorize :::J-0V,0H /41.4/Zi" 0 U to act on My behalf, in all tters relati e to work thorized by this building permit application. Signature of Ow& Date T— SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 3 �a 1 t North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant e,/Ml Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Town of North Andover` Building Department 27 Charles Street North Andover, MA. 01845S4nTtD r, FPµy�i Su.CNL45��o� D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE �l ��1 D% JOB LOCATION Z 1 "T - Number Number Street Address Map / lot "HOMEOWNER '�o��,Pi} MP?—1 00 'F-7'5 Co$�l-$X57 Name Home Phone Work Phone ,e PRESENT MAILING ADDRESS 1 Z--7 1 u P,'1 Pilo (LT» opt. d4 -(L- (Yl a + City Town State Zip Code The current exemption for "home6wners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and re uirements. 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In 0 C: �$ CL r) OTI 0.0 M Oq rA W 0 . 7WE 61 %45_5,4e t<u5s-1 7s 1Jyaast »ext o� PP -d& S44 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use ^^�Onry Permit No_ /&fd3 Occupancy & Fee Checked 'SFV APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts E'.ectncal Code 5x2;7 CMR 12:00 J/ q �_ (Please Print in ink or type all information) Date ✓ To the Inspector of Wires: .- Town of North Andover The undersigned applies for a permit to perform the electrical work described below. r, Location (Street & Number 2 ' tt( ��4 w4 1 - 6ic2au-6. Owner a Owner's Is this permit in conjunction with a building Purpose of Building J�L Yes E No ❑ (Check Appropriate Box) Existing Service E � Amps vp �y Voits New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Overhead ❑ Authcrcmdcn No/_ Undgmd No. of Meters Overhead ❑ Undgmd ❑ No. of Meters 11TucA• /[ n�ep�/ ! � �/Ui��i A. I�.O/P// 7/l/!1%S /lie t75 �/%YJ C 7 /(�L�� IGQi%� /� �.J�'�TC^ r` �%N IkIl INSURANCE coveRAGE. Pursuant to the requiremen6ts of MasVaCnusetts General Laws / ' I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the a of coverage by checking the appropriate box INSURANCE = BONO = OTHER = (Please Specify) i�o2" ! 0c) _ O J (Expiration Date) Estimated Value ect ' rma Works 5 Work to Start IY Inspection Date Resquested —Rough Final Signed under the Nin s 4;fperjury:^ /` JAG y FIRM NAME [S/L Lam/ 9 / LIC. NO. 37 m!-1�7U/U/C 6� LIC. No. J7 o d 17- f�-1 Bus. Tet No. Add sss Alt Tel. No. ------- ER'S INSURANCE WAIVER: I am aware that the Licen es does not have the insurance coverage or its substantial equivalent as required by Massachusetts Gen ''I Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) �i Telephone No. PERMIT FEE 5�---- (Signature of Owner or Agent) Total No. of Ug ht8n Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Liqntinq Fixtures SwimmingPact qmd C gmd C Generators KVA No. of Emergency L.ignring No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Bumers FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diooaal No. Pumas Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Soace/Area Hearing KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW signs Sadases Wiring No. Hydro Massage Tuds No. of Motors Total HP 11TucA• /[ n�ep�/ ! � �/Ui��i A. I�.O/P// 7/l/!1%S /lie t75 �/%YJ C 7 /(�L�� IGQi%� /� �.J�'�TC^ r` �%N IkIl INSURANCE coveRAGE. Pursuant to the requiremen6ts of MasVaCnusetts General Laws / ' I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the a of coverage by checking the appropriate box INSURANCE = BONO = OTHER = (Please Specify) i�o2" ! 0c) _ O J (Expiration Date) Estimated Value ect ' rma Works 5 Work to Start IY Inspection Date Resquested —Rough Final Signed under the Nin s 4;fperjury:^ /` JAG y FIRM NAME [S/L Lam/ 9 / LIC. NO. 37 m!-1�7U/U/C 6� LIC. No. J7 o d 17- f�-1 Bus. Tet No. Add sss Alt Tel. No. ------- ER'S INSURANCE WAIVER: I am aware that the Licen es does not have the insurance coverage or its substantial equivalent as required by Massachusetts Gen ''I Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) �i Telephone No. PERMIT FEE 5�---- (Signature of Owner or Agent) N2 Date... .. ............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... C ...................... ... has permission to perform :41: ...... .... wiring in the building of Z ..................................... � at......... . ............................................................. North Andover, Mass6o R .. ................ 'EEA—L—iN;P—E' C**T* 0** ................ Fee .ate � ............. Lic. N2� to 0 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer