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HomeMy WebLinkAboutMiscellaneous - 148 WEYLAND CIRCLE 4/30/20187 0 8i00 00 al :E Q (mr N D Ut Z (P v 00 o A o 0m O y�n Tile Commonwealth of Massachusetts `%V u''' a IUD �••rell Vin, � �� O Department of Public Sofcty OecuP•r nc) ! r.e tlieeked....... BOARD OF FIRE PREVENTION REGULATIONS 527 C1.IR 12:00 3/90 ilea.e blink) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK NI work to be performed In accordance wish the Mauachusetu Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 7 _ 9 — 1 City or Town of IV D,er 4NDD✓ee To the Inspector of Wires: The undersigned applies for a permit to perforo the electrical work described below. Location (Street 6 Number) /4/0 14JEyL,4Ao1,0 L'LE O% -mer or Tenant Owner's Address SAME Csa$ «7— V2 -1r Is this permit in conjunction with a building permit: Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Utility Authorization 110. Existing Service Amps / Volts Overhead ❑ Undgrdl 1 No. of Meters _ flew Service Amps / Volts Overhead ❑ Undgrd ❑ 110. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation of Alarm System No. of Lighting Outlets No. of Hot Tubs ' No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners t No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No.of elf ContaineDetecding Devices ❑ Municipal ❑Other Connection No. of Ranges No. of Air Cond. Total tons No. of DisposalsNo. of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KWLocal No. of Water Heaters KW Sisnsf Ballasts Wiring tag No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I have submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work S Work to Start 7-.P—,9 7 Inspection Date Requested: Rough Signed under the penalties of perjury: FIRM NAME A.D.T. SECURITY -SYSTEMS NORTHEAST INC. Licensee DONALD A BROOKS Signat e Expiration Date Final 7-11-97 LIC. No. 12 31 C LTC_ Nn 12310 Address 60 William Street, Wellesley, 8 'Bos• Tel: No.413-732-4400 Alt. Tel. No.617-431-5831 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or rts sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) DD Telephone No. PERMIT FEE S 35 Signature of Owner or Agent GV 0 1 �ky- Date.. 7 J 1053 Z ? NORTH °f<� `°;•'"o TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING ,SSAC14 f This certifies that �!• r lA 1) / S -�'.:..D....�......... �..5. �..1�. �.....�......�... J............ has permission to perform .................�.�.. ..? ...?......... � .. .....!.................... wiring in the building of........:1............................................................. Q at ..... 1.`.jq...... t�..� �:4 .......�.f..'�. �........... , North Andover, Mass. Fee ... . `e .: ��.. Lic. Nol . `............ �......1 .....::................. ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer p I� N 4 u G Date t. pORTN TOWN OF NORTH ANDOVER Oft.a° ,e ,b0 3? 'PERMIT FOR GAS INSTALLATION SACHUSES 4 N This certifies that . %:,�.. �� • • • .1 •,� �✓� •�'�• • • CU has permission for gas installation ../..�.F...,�ff..<c'.n in the buildings of .4-:.. :........................... . o, at ./.Y...:..::: t :. �.. (:...... , North Andover, M48s. a Fee.j�...... Lic. No........... ....................... ". GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 9L\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING C a — (Print or Type) Yl Mass. Date vZ 19Permit #�L ` c Building Location Owner's Name, f %Lp 1 , Type of Occupancy It Q'New p Renovation Replacement p Plans Submitted: Yes ❑ ❑ Installing Company Name Address & AIR ONDITI ,7NIn�rHEATING . —NQRrH P•o. Bonx 21 8 Business Telephone -- /©00 Name of Licensed Plumber or Gas Fitter ,Jf/4-RPI _j% 671-6 Check one: ❑ Corporation ❑P rtnership Firm/Co. Certificate # INSURANCE COVERAGE: I have a current It�.bllity Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes U-, No ❑ !,%you have checked Yes, please Indicate the type coverage by checking the appropriate box A Ilabllfty Insurance policy Q- 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 permit Iss ed for this application II be In compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the a ral laws. [EBY T e Ucense: lumberrgnalure o nse um er Gas ter le asfillor Master Ucense Number %� 90-7 ty/Town Journeyman 'I'11CyW) 0 C 70-7-0-M7— • ilk ' ■■■■■■■■■■■■■■■ ■ ■ON MINN ■■■■■■■■■■■■ 1010 ■■1010■■■mom ' ' ■■■■■■■■■■■■ 1010■■o■■■■■■■■ ... own ■1000■■■■■■■ n■■■■■■■■■ .. ... ■■■■■■■■■■■■■■ ■■■■■■■■MEN • • ■■■■■■■■■■■■■■■■■■■■■r■r■ IN .. ■00010001001001010■1010■ ■10■ ■0■ •• ■■■■■■■■■■■■■■loom ■ ■ ONE ... ■01001000100001010010010■■■ 10mom00 so Installing Company Name Address & AIR ONDITI ,7NIn�rHEATING . —NQRrH P•o. Bonx 21 8 Business Telephone -- /©00 Name of Licensed Plumber or Gas Fitter ,Jf/4-RPI _j% 671-6 Check one: ❑ Corporation ❑P rtnership Firm/Co. Certificate # INSURANCE COVERAGE: I have a current It�.bllity Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes U-, No ❑ !,%you have checked Yes, please Indicate the type coverage by checking the appropriate box A Ilabllfty Insurance policy Q- 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 permit Iss ed for this application II be In compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the a ral laws. [EBY T e Ucense: lumberrgnalure o nse um er Gas ter le asfillor Master Ucense Number %� 90-7 ty/Town Journeyman 'I'11CyW) 0 C 70-7-0-M7— J z 0 w w U LL LL O Ir O LL 3 O .J w m N) w S U F - w Y N 0 tl Z• h h LL N tl O 0 O h h_ tl U, O W z o, a O LL z O h Q U J CL CL a w C1 w N tl U. 0 tl z a o tl w J Z � a b J LL LL O C1 N tl a �• O X O a O cc W w wx m O z a ] 0 Location Ci D t� No. _� ` _ Date IV744?r— TOWN OF NORTH ANDOVER Certificate of Occupancy $ �U Building/Frame .Permit. Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 0 5 `,I&, o9/% 11:59 Building Inspector 150.00 PAID Div. Public Works Locl'ation /�/ / i N6. — . Date 11 A O IZ07 �d e A TOWN OF NORTH ANDOVEFF Certificate of Occupancy $ i Building/Frame Permit Fee $ 14, Foundation Permit Fee $ Other Permit Fee $ _LO Sewer Connection Fee $ Water Connection Fee $CU l Z TOTAL $ ui ' g cto s, H82 2 Di . 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C7 cc 0 .m C �y7 a � CL gm m C2 m m N o � cpm am IM IS O p� ti C,cr ccl a CA Oto ,.. .� m N Cos � yONJ :^ O O O N Er O CD CD F �CD �Lv \� N o C d w Cm n Cl) C2 O � n r. cn; C/) p� ^ '' 7 � G ��r Cn G Cl. iT7 g i r G. 0° ►� ori G G G w a. w T .b 0O r* a CA to C O �.o z o �J C r �o GN omi 0 9 0 c v� y r r� o d °zOil d o x x CrJ y � y y 1 V �I z n O A z d � r� m m 0 m mn -1n O m 00 Z � O C Ch 3m go =1 O CL O � C Z n FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: _to X wed a/ lRe a /%-y o y � Phone 1-/ LOCATION: Assessor's Map Number Parcel Subdivision -f-0 X 1A)n� Lot(s) y Street 1.a.0 Cf rc St. Number _/ y ************************Official Use Only************************ RECO DATI4Adi tT AGENTS: Date' Approved Conservationstrator Date Rejected Comments C 't9 -P Date Approved q (n Town Planner Date Rejected Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved 41 A Date Rejected PlIr- DateApproved Date Rejected Public Works - sewer/water connections %^w driveway permit��) Fire Department /9 Le Received by Building Inspector �l Date Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. 7Na of Applicant on Building Permit (below) Address of Property for Permit (below) o Wood& J /7- Co% yS "V�a r� C/ C, r gap and Parcel: Purposeo Application (check below) Phci 7e ra pe�f Applicant: Single Family Two Family 1 theundersignedapplicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning I w. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is grounds for refusal by,the Building Department to issue a Building Permit. i' l/lag 4,1 1 ure of Owner or ut orized Agent who Csig�ne_d the Attached Building Permit Date form must be attached to the Building Permit upon application for such permit. Pt2aaostp 11vusE /N Vo . ,Q•voo vele 0,e,4,el V F02 ,e ¢, /99G �lE.P,F'/�tf,4Gr E-,vG�•t�EE.P/.f/6 SE�PY/lEs 1,4S.S,4,,WX, 77S O/B/D :v CA C d CA CD d 'C O n Z y 06 C2� ? O as y O to O v CD CDCL O rF Q =r CD Er CD O CD C CCD y� dv y -• o cc CD � v CA10 O CD Z •CD CD 0 Cr] VqJ -1 ON K 0 I C E--"— � o N y a_ M e• c� m O d0 I m N•� �-c N .�-� END. N T d?d 199 _Io CO N o y o t m O N. n O ? _ CO) C36 m N cro C26 O H Imcr N 06M c Q' � O O co O 1 • N E N O m � MAR m y� C2 :CO CD W � 9 N C. o® a 3 CD Im �- z ate: 1 co � co �q r1 N 1tri �I•rryF:j p ao r.' qac yJ ty'CAx �0 n? �' o ,.� y tz �' 0• b y ^ ...,,4';'�•.gnw""m1.4„T"�a�.!'-9w� .' ^..""Mtcm�aa •....},.--.�. r -� �s^'re4�e � ..w.... �r-s r Date.....!! --:5eq—a7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING Tf�'6 -'-- Thiscertifies that ........................................................................................ has permission to perform .......... wiring in the building of ..................... .......................................... at ..... ......... w North Andover, Mass. Fee.:5 Lic. Nn.;�M............. ELECTRICALINSPECTO Check # ME Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ' e l`S Occupancy and Fee Checked [Rev. 1/071 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 IN INK OR TYPE ALL INFORMATION) Date: 1W, 16 City or Town of: NORTH ANDOVER To the InspecYor of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) — 2Llb n dL, Owner or Tenant F l ym yi , Telephone No. Owner's Address,tjyy1.(� Is this permit in conjunction with a build' n permit? Yes El No El (Check Appropriate Box) Purpose of Building yt Utility Authorization No. Existing Service Amps / Volts 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: 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 ]Swimming No. of Hot Tubs Generators KVA No. of Luminaires Pool Above ❑ In-El rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Number I ons I KW I No. ofSelf-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mun'c'pal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts 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 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, under the pains and penalties of perjury, that the information on this application is true and complet . FIRM NAME: -.jam!..! �,/,-e,Trl 1( �jr ;��C' LIC. NO.: 3 Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: 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: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ Commonwealth of Massachusetts Official Use Only r Permit No. —/ WX Department of Fire Services ;. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (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 IN INK OR TYPE ALL INFORMATION) Date:_ City or Town of. NORTH ANDOVER To the Inspe or of[fires: By this application the undersigned gives notice of his or her intentign to perform the electrical work described below. Location (Street & Number) ZY Y — -0 L /" Owner or Tenant --Li-Ki i r-,- a y, . Telephone No. Owner's Addressy�.� e Is this permit in conjunction with a buildin permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building_r:,) ' vt j 1, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- F -1 rnd. rnd. o. o Emergency Lighting 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposersea Number ons KW No. oSelf-Contained Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mun'c'pa ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Te eco of Device o r Wiring: No. of Devices or E uivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (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:) 1 certify, under the pains and penalties of perjury, that the information on this application is true and conrplet . FIRM NAME: TL, EJ�1,%r1 t�' .1�'�C' LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: 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: 1 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. $ I he Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 "Sl - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information g % /r1 �-- Please Print Leibly Name (Business/Organization/Individual):0614 `�C� / � t ( � C Address: 5-F° Ct /O�!/M City/State/Zip: Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. Tsub-contractors have orkers' comp. insurance. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type oject (required): 6. o rNew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs l3.❑ Other *Any applicant that checks box #I 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 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: Policy # or Self -ins. Lic. #: Expiration Date:? Job Site Address: %' 12✓1 IT � e,� &2)2 ( (_ f% 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 cert' th bT syn1 penalties of perjury that the information provided as ov�CO 's''trJue and correct. Ciannfirra L.- 1 "� r)ata• V / 2 / 03-ft3 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 #: 011E &MIIIUIUUraffij Df fRagBafJ1UBtttB Ikpartturnt of Vublic tufrtU BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only Permit No. (p Occupancy ,& Fee Checked 3/90 (leave blank) til y L APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 2; :22-3A City or Town of --NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) , f� &_(/l p, t 0k k1d CLlt Owner or Tenant � / Owner's Address 3 c rej lL:!I ,.n_tC oy, iL Is this permit in conjunction with et building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building __ ,..S 1. �2.(( a U_ J+�rya Utility Authorization No. bo / 3,( Existing Service AmpsJ_I Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service 2 -OU OU Amps ZVO Volts Overhead ❑ Undgrnd -rff No. of Meters Number of Feeders and Ampacity r 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 In- ❑ ❑ grnd. grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners v Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of Air Cond. Total tons Initiating Devices No. of Disposals No.of Heat Total Total s Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Local Municipal Other ❑ No. of Dryers Heating Devices KW Connection _J No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES,� NO ❑ 1 have submitted valid proof of same to the Office. YES 40 NO ❑ If you have checked YES, please indicate the typ1 coverage by checking the appropriate box. INSURANCE t BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ _ Work to Start 1� Signed under the Penalties of perjury: FIRM NAME 41WLcJ1`QnJC'�t Licensee Inspection Date Requested ignature Rough (—k,1l Final LIC. NO. /r /ten 4- � LIIC..�NO. Bus. Tel. No. Alt. Tel. No. OWNER'S INSURANCE WAI)(*4R: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Date ........ 632 TOWN OF NORTH ANDOVER 4MO .A PERMIT FOR WIRING This certifies that ......... ....... ...... ........ has permission to perform ........ W.C.w. 97 ........................... ........... ..... vl� J3 ......................... wiring in the b ilding; �f ........ t�- ...... CU at f........... . North Andover, Mass ... .... ..... . t!4 Fee.28e .. !Lic. NoJ.!..W7J ............................................................. ELECTRICAL INSPECTOR CU WHITE: Applicant CANARY: Building Dept. PINK: Treasurer