HomeMy WebLinkAboutMiscellaneous - 134 OLYMPIC LANE 4/30/2018 (2) 134 OLYMPIC LANE
210/106.B-0123-0000.0
1 �
Date. ?/Z.5 ,/ .S....
NOR7M
TOWN OF NORTH ANDOVER
° ' p PERMIT FOR WIRING
SSACMUS�
This certifies that .i yi............?..!.........l...............................................
G�
has permission to perform ...........................
wiring in the building of....
............... .North Andover,Mass.
Fee..�............. Lic.No:�.:-`�S. .............. ..,....I... ....::�7..........................
LECTR[CAL INSPECTOR
Check # -� v
4744
TBE COAMONWF.ALTHOFMASSACHUSETI S Office Use only
DEPAR7MENT0FPUXJCSVM Permit No. L{7(/
BOARDOFMEPREVENHONREG4ffATIONSR70MRI2 010
Occupancy&Fees Checked
APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 9 Lrk
Town of North Andover To the Inspector of W
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number) 3 0,i
Owner or Tenant P ��, A 4,
Owner's Address
Is this permit in conjunction with a building permit: Yes o No (Check Appropriate Box)
Purpose of Building - Utility Authorization No.
Existing Service 'Amps mvolts Overhead Underground No.of Meters
New Service Amps / Volts Overhead Underground No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total
KVA _
No.of Lighting Fixtures Swimming Pool Above Below Generators KVA
round ground
No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units
No.of Switch Outlets
No.of Gas Burners
No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones
Tons
No.of Disposals No.of Heat Total Total No.of Detection and
Pumps Tons KW Initiating Devices
No.of Dishwashers Space Area Heating KW No.of Sounding Devices
No.of Self Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal Other
Connections
No.of Water Heaters KW No.of No.of
Signs Bailasis
No.Hydro Massage Tubs No.of Motors Total HP
OTHER' C' r 11. /&— .S V
htsttra=Covmge.RusuanttothetagmariailsofMamdmsettsCtnw,llaws
IhawaamattLiabkhm mnaePbhcyinch>dmgCon>pleV- Comageoritssubst<vMapvabt YES NO 1
IhawwbmwdvandploofofsantetotheOffim YES EI ffyouhawdrdcedYES,pkaseitxhcaiethetypeofcovwageby
drd<irgthe box
INSURANCEBOND r7 GII-ER F-1 ftaseSpedfy)
EVirafimD&
fti&
Ed Value dT!dncal Wotk$
Wotktosm IrW0CfiMD&ReWested Roue Final
Signedutxlert& o peiw- �1 n
FMMNAME
Lioel>9ee Signattue �- LimmNo
n 'BtsrmTel.No. 92(R- Pi-/-s�-rX
Arirlirec C"� Gc', XVSCv /Vo • Alt Tel No.
OWNER'SINSURANCEWAIVER Iamawacetha&Lic wdoesnothawthemsur&ceoova2georitsabstmtolequivalattaswgttitedbyMassackttm Gm alLaws
and that my signature on this peurut apptcagon waives this mwitmtem
(Please check one) Owner Agent
Telephone No. PERMIT FEE
tgna ure o _ wner or Agent
ISI
z The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
w~ Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
Name:
Location: r
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers compensation for my employees working on this job.
Company name:
1
Address JI °
City 4 Phone#:
Insurance.Co. Policy#
Company name:
Address
City Phone#
Insurance Co. Policv#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00
and/or one years'imprisonment_as welLas_chni.penattiesinshelffin-fa_STOP W9RKORDFRond_a.fine_of_($1DOM)-atlay.against_me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the intarmation provided above is true and correct.
Signature Date
Print name Phone.#
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing.
Building Dept
E]Check if immediate response is required .0 Licensing Board
E] Selectman's Office
Contact person: Phone#: ❑ Health Department
Other