HomeMy WebLinkAboutMiscellaneous - 14 Margate Road � BUILDING FILE'
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Date. ........
AORTH
4,6 TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that .....k.e.O.Q...... ......... ...............................
.. .. ... ... ... .. .. .. ... ...
has permission to perform .....V.e-.LA ..... ......+0......P.C.:).O..(......
wiring in the building of.... .......�a IJ..............................................
14
at............... ............................................ .North 4ndover,Mass.
Fee....QP.—.... Lic.No.kRo.99 N)IeWA I pqf� Llrv,
........... ...I.. .. .............
�E"C�T*R*I C,'A'L, N-S P Ek T 0 R
Check #
5283
THE COMMONREUMOFMASSACHUSETTS Office Use o --
DEPARTMENTOFPUMLICS4MY1 (
Permit No.
BOARDOFFIREPREV_ENI70NREGUTA770NS527CNIR12.M �
fOccupancy&Fees Checked
APPLICATTONFOR PERMIT TO PIMiUssITSRMELE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSELECTRICAL CODE,527 CMR 12:00 /
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION), Date 1./ 1114
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the ele trical work escribed below.
Location(Street&Number) l
Owner or Tenant A
Owner's Address r—
Is this permit in conjunction with a building permit: Ves M No r 7L-**" (Check Appropriate Box)
Purpose of Building S C,,//1;7/n i A /P®0 /4AI n p-L,,� 9 ro vId Utility Authorization No. ........ �
Existing Service Amps / Volts Overhead M Underground M 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 M ,
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 NQ,of Sounding Devices
M;`-f Self Contained
Det6bti6n/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal Other
Connections
No.of Water Heaters KW No.of No.of
Signs Bai]asis
No.Hydro Massage Tubs No.of Motors Total HP
THER-
;t DXCovarage:Rina=totheteWknotscfMffisachuseffsGemalLaws
aveaamotliab>btyh oelblicyinclu)gComple Cowrageoritssul=tialegtrival t YES NO
avesubnriuedvalidpmofofsaurtothe0ffice YES IfyuibawdedodYES,p)easeitx thetypeofoovetageby
Dd&g thebox
SURANCEM BOND F-1 MIM F'—J (Please Specify)
Eviration Date
Estitnaed Vakr of>karical Work$
xktoStart 4////eZ InspecfionDaleRapested Rough Fir
nedundertTiePer altiesofperjury.
MNANM Lic=No.
nsee _leO h AV.. Signal= 11offiseNo _16S,Z&/, 96 '7
/p� J Busi1essTe1N0.q 7 k- 7 6 o
Vr✓�ltJ ,� !L� /�. ✓t dy-e,/ �, AIL Tel.No.
N�2'S INSI ANCE WAIVER;lam aware that the License does notballe the ffI% nx>✓ODNMOe orits sut ial eclui dent as tegmed byMa--,c u-tem General Laws
that my signalutE on this peurnt application waives this mquir ml
:ase check one) Owner ® Agent
Telephone No. PERMIT FEE$
Signature oT Owner or 7gent
_ X The Commonwealth of Massachusetts
Department of Industrial Accidents
9 dents
Office of Investigations
Boston; Mass. 02119
Workers'Compensation insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
aI 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:
Address
City: Phone#:
Insurance.Co. Policv#
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 well_as_civil.penaltiesin.2helorm-fa..STOP WORK ORDFR..and..a.fine.of_(.$1.DO..0Q)_atiayagainst.me.
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 information 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
0 Building Dept
❑Check if immediate response is required Q Licensing Board
Selectman's Office
Contact person: Phone#: Health Department
Other
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