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HomeMy WebLinkAboutMiscellaneous - 15 EMPIRE DRIVE 4/30/2018 f Iti E��ee �e l BUiLDING FILE i Date. .� Th2-. . . 948E NORT: a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SswcNusf� This certifies that . . . . . . ��'�5� has permission to perform ./1'e&/j plumbing in the buildings of . . . . . . . . at . . . . . ,i�. il.-O. . . . . . . . . , NJ n/dov r, Mass. Fee. . 00'leOO Lic. No.. ja� str. . . . . . . . . . . . PLUMBING INSPECTOR Check # -�'� i i 4,ZX MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i CITY Y`tom N by'- MA. DATE '7- 11--/?- PERMIT# JOBSITE ADDRESS OWNER'S NAME Or du. ' POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALA,, PRINT NEWRENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO ElCLEARLY J- FIXTURES Z FLOOR- BSMT 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER j FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY - ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes&'No❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information 1 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 General Laws. PLUMBER NAME STEP4EA3 C_ GALINSKY SIGNATURE LIC# 10311S MP[' JP❑ CORPORATION Pl'# 319(- PARTNERSHIP ❑# LLC ❑# COMPANYNAME 6AL4A3SKY PLUMD{A1b geATiLIADDRESS: P.O. Box (701 CITY NAva<aKIL'L STATE rA•A- ZIP 01%3-1 EMAIL VVWW. mf plomb>`>rW1 . Cowl TEL (OV-37q- 0,43 CELL SOB-5OCI 590 1 FAX C1715-5-Al-'4131 4 ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 0 Yes No THIS APPLICATION SERVES A$THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NO'I'ES r Date. .��S/.! Z ....... . HORTp 3= �' TOWN OF NORTH ANDOVER O � 9 • - PERMIT FOR GAS INSTALLATION SA US This certifies that . . q�. . ... . . . . . . . i has permission for gas installation ./14PA16 � in the bu'Idin s of jS Q s . . .a -. . . . . . . . . . . . . . . . . . . at . . . . r� r .t!/. QL4ti. . . . . . . ., North Andover, Mass Fee. ,,o. :P5� Lic. No../6;-� . GASINSPECTOR Check# 8251 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY. MA. DATE: 7 j F`YZ PERMIT JOBSITE ADDRESS: k;-1 �`� �ty► jJCr'C, VJMAOWNER'S NAME: C9)rAVX V, GOWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES? FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE t GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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. LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance Y re coverage required b Chapter 142 of the q P Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT E]SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are trueland accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will in i ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME:.. STEPyFN C GALZNSKY LICENSE# 10345 C SI COMPANYNAME: C,AL1►KII Pd.006106 -t- 9M- f-(hJ& ADDRESS: P.0- ROx 1701 CITY: MAVE7KHuL, STATE: ►n-A- ZIP: 01831 FAX: 521-41St TEL: 979-3'7y- 17y3 CELL: 504- 50 - 5q0✓y EMAIL: w'vv'W• mC' 1umbe MASTER(i JOURNEYMAN❑ LP INSTALLER❑ CORPORATION/ 31 gG PARTNERSHIP❑# LLC❑# ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES f Yes No G THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �Z v FEE; $ PERMIT# PLAN REVIEW NOTES E ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 17 Yes No /rz�z �^ a THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �� v FEE: $ PERMIT# PLAN REVIEW NOTES Claim #5517162 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA 01845 Re: Insured: Xiaojin Qiu Property address: 15 Empire Dr. North Andover, MA 01845 Policy #: 5517162 Loss of: 1-2014 File or Claim No. AD 9914 Claim has been made involving loss, damage or destruction of the above _captioned property, which may either exceed $1, 000.00 or cause Mass.—Gen..-Laws,-Chapter-143,-Section-6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. O1-22-14 Signature and dater.- Claim #5517162 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner aor/ Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA 01845 Re: Insured: Xiaojin Qiu Property address: 15 Empire Dr. North Andover, MA 01845 Policy #: 5517162 Loss of: 1-2014 File or Claim No. AD 9914 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1, 000.00 or cause Mass._Gen.._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 01-22-14 .Signature and dat64-- 6 G - Date. . . . ...--.. .7" NpRTM TOWN OF NORTH ANDOVER p.1 ,E'6 FO? y` n p 9 PERMIT FOR MECHANICAL INSTALLATION 4 r �9SSACMUSEtt This certifies that . f i, `. �. . . . . . . . . . . . . . . . . . . . . . . . has permission for mechanical installation . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of /: .1:.:%?, Fi' . . .% . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. <: .`'. . . Lic. No.. . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of:Massachusetts Q� .Sheet ?Metal Permit Date: pj - Permit Estimated Job Cost:g_ c i Per-mit Fee: $ 1 Plans Submitted: YES NO ?tans Reviewed: VES NO Business License 4 . _ ,.ppIicant License Business Information,: Property, Owner/Jots Lceatior. Information: Nam .1 _- name: Street: ��( (�'J/ — �} y�� Street. Cityri Gw.' � � CityJTown: Teiephorte: 9w- Telephone. i Photo I.D, required/Copy of Photo I.D.atta;hed: YES N Staff Initial J-1 i �-,_,nrestrictrdse J-2!M-2-restricted to dweilings?-stories or!css and commercial up to 10,000 sq. /2-stcrie3 or less Residential: 1-? farniiy_$ Multi-family Condo!Townhouses Other Commercial: Office Retail Industrial Educational Instivitional Other Square Footage: under 10,000 sq. ft. _P� over 10,000 sq. ft. Number of Stories: Sleet metal work to be completed: New Work: � Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Motal C}ti:-tney I Vents Air Balancing Provide detailed description of work to be done: C p. 2 INSURANCE COVERAGE: I have a cur.ent Iiabilfly insurance pciicy or iia equiva!n.nt Nhich meets tha requirement$of M..O.L. Ch. 112 Yees No If you have checked Yes,;nditate the type of coverage by checking the appropriate box belo%v: i A liability irsurance policy Other typo of indemnity ❑ Sond ❑ OWNER'S INSURAHt E WAIVER:I am aware that the Ii,ansae does not-have the insurance coveraga rdquirsu b---V Chapter 112 of the Massachusetts Ceneral Laws,and that my signature on this prarmit application waives th's reeuiramant. Chick One Only Owner ❑ Agent Siyrai.ua ct Gta:rer or Owner's Agen; i By checking thi9 boxF,I hereby certify that all of the details and Information I neve submitted(or entered)regarding this a�cr.lication aro true and accurate to the tr09t f my kno%viadye and that all sheet metal Work and Instailatlo,ns Kertormsd under the permit Issued for Innis apocation will Le In compliance with all pertinent provision of Ll:Massachulatft 3Lildin6 Code and ClIapter 112 of the General Laws, Duct Inspecticn requlrad prior to Insulation installatlnn: YES Progress Inspections Date �t?tments final Inspection Date C:attZm.en-1 ype o`Licanse �— ------ — IS I y Ttle ❑Pol9ster-f2astricted � ,,� ❑,io.+rneypersc-n Permit# Signature of .+censz-m — � ��Joarnaypersan-Re6'rh;ter. LicenS@ Nurser. Fay S Check a;www.mess.go,,1(inI I Inapactpr 3tpnature of Permit Approval ,per V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 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):��- a �r}�—, ,)r� O ((AC� �y I c4 Address:/ ��r�'1 � I ��� s)-m- l City/State/Zi �^ Phone#: , - �'" Are you an employer. 4ffheck the appropriate box: Type of project(required): 1.0 I am a with employer 4. ❑ I am a general contractor and I �— 6. E] 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. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 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. 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: C cub L f), Policy#or Self-ins.Lic.#:"?p toe_ Expiration Date: Job Site Address: J nl jio_ 71— City/State/Zip: IV 19 - 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 cernA under the ains an penalties ofperjury that the information provided above is true and correct Si ature. tL, Date: Phone#• 22R-- /170:-22 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#: AC<>R& CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) �.� F03/26/2O12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY, INC. PHONE", Eg; (918) 686-2266 F"" c97et 686-6410 (AIC, No): E-MAIL cfernandez@nafins.com M.J. FOSTER INSURANCE SERVICES ADDRESS: PRODUCER 163 MAIN STREET cusroMER ID R•A . Mechanical, Inc. NORTH ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A :PEERLESS INSURANCE CO R.A. . Mechanical, Inc. INSURER a :GUARD_ INSURANCE 16 LOmar Park INSURER C Suite 1 INSURER D INSURER E Pepperell MA 01463- IINSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I -DD iF POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYI^n (MMIDDIYYYY) LIMITS A GENERAL LIABILITY Y 11 P5337500 1/01/2012 01/01/2013 EACH OCCURRENCE $ 1,000,000 X ,COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 PREMISES Ea occurrence CLAIMS-MADE f X j OCCUR / / / / MED EXP(Any one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG j$ 2,000,000 X 'POLICY PRD LOC / / / / EBLIA $ A AUTOMOBILE LIABILITY BA8832363 .01/01/2012 01/01/2013 COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ XSCHEDULED AUTOS / / / / - PROPERTY DAMAGE $ X HIRED AUTOS / / / / (Per accident) _! NON-OWNED AUTOS � $ A X UMBRELLA UAB X OCCUR 8825678 01/01/2012 Pl/01/2013 EACH OCCURRENCE Is 1,000,000 EXCESS LIAB CLAIMS-MADE / / / / AGGREGATE $ 1,000,000 DEDUCTIBLE / / / / $ 7 RETENTION $ / / / / $ B WORKERS COMPENSATION AAWC231923 01/01/2012 01/01/2013 � WCSTATI IU- OTH- AND EMPLOYERS' LIABILITY YIN TORY L M T ER ANY PROPRIETOR/PARTNER/EXECUTIVE OF EXCLUDED? ❑ N/A i / / / / E.L.EACH ACCIDENT I$ SQO,OOO (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,_900 If yes,describe under DYSCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-1301 ICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it mom space is required) CERTIFICATE HOLDER , CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. R.A. MECHANCIAL, INC. 16 LOMAR PARK AUTHORIZED REPRESENTATIVE SUITE 1 PEPPERELL MA 01463- . ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(20OW9) The ACORD name and logo are registered marks of ACORD Sheet 1 is �K t � 09-1�y x� �f+MGG►sk��®y CfM VQ 2ef{f/`,� first flnOr (i�/�( �r�cf j� SIJ hall II 6„11105 cfm ill I '# Ictm iivn y�wi +ii C ,Air AkrA Job#" RA MECHANICAL INC Scale: 1 :64 Performed for. Page 1 BOB MESSINA 16 LOMAR PARK Right-Suite®Univer3al EMPIRE DRIVE PEPPERELL,MA 01463 7.1.25 RSU11207 N.ANDOVER,MA Phone:9784338671 Fax 9784334900 2011-Feb-24 08:13:59 ramechanicalCaol.com ...arty orchard village 2-23-11.rup 2nd floor r CEM r cfm7 cfm C= vwiel 2nd floor cfm :F1Efm cfm master bed ® 19cfm C 116cfm Job#: Performed for. RA MECHANICAL INC Scale: 1 :64 BOB MESSINA 16 LOMAR PARKPage 2 EMPIRE DRIVE PEPPERELL,MA 01463 Rlght-Suite®Universal N.ANDOVER,MA 7.1.25 RSU11207 Phone:9784338671 Fax:9784334900 2011-Feb-24 08:13:59 ramechanical aol.com 71)e WQ�.f` erly orchard village Z-23-11.rup x zz 97 MASSAC`HUETT DRIVER'S =� LICENSE �. OF M,�S,q _+,•.' '", - { sex M ...... �. .......... - L TTE' ::. J MAMMOTH RD - DRACUT,MA 01826/349 - __ �_ /��•- 5 DO09.0]-2010R.v07.1S2009 COMMONWEALTH OF MASSACHUSETTS SHEET METAL WORKER5 AS A MASTER-UNRESTRICTED ISSUES THE ABOVE LICENSE TO: DONALD J 011ELLETTE I 657 MAMMOTH RD DRACUT MA 01826-4349 4688 07/28/14 223139 ! LICENSE NO. EXPIRATION DATE SERIAL NO.- J• ` Date •..bk.�y'LFL�c45 .. I , TOWN OF NORTH ANDOVER E PERMIT FOR WIRING f This certifies that . . . .4P. f. ./ . r p has permission to perform . . !� : .-. . . .,�1ir.�- . . ./ : . .t; . . . . . . F I. wiring in the building of . . .6 . . . . �* .t ra.�. .. . . . . . . . . . 4 _ R at . / ./,:;. „"y�,�r�- :�. . . . . /,. �. . . . ,North Andover, Mass. Fee . . .1/��- r ic. No./, F ELECTRICAL INePEC O Check 4,/,7tiZ 11023 ' Commonwealth of Massachusetts official Usc only Department of Fine Services Pamit x°• BOARD OF FIRE PREVENTION REGULATIONS C��and Fee Chel v. 1/U7,� cave blank APPLICATION FOR PERMIT TO PERFORM EL AN wpm beedin ELECTRICAL ace with the M WORK (PL&M PA Off N.IN�C OR MEAS INFY�IRM 270 Biecrricat Coda(MEC),327 CMR 12.00 QtY or Town of., NORTR Date: /y � ANDOVERTothe By this lieation the undersigned +es nutire Pe�or ofres: har irnentlan m Location(Street&Number ev ��� electrical work described below. Owner or Tenant t Owner'sAddress Tele No. Is tufa permdt in eouJanctfon with s bnQdtng Yes ❑ No PilrpOle afB�fldt+dg .jj f ��ri. / ❑ (Check Apprepr3aft Bcur) EAgtftg Service Aim aUtffftp AUthortzation No l3 y 3�/ 'y Overhead n IInd�d o NO.of Meters NW-M— ora Ampg !Z o.volts Overhead❑ uaH Number of Feeders andAmpacity grd Q--- No.of Meters Location sad Nature of Proposed Electrical Work. _— No.of L�eg hol"o the oil table he wgfwd h the ro " Na of C41-SUMP.{Paddle)Fans 0• g'ines No.of Lumdualre Outiets Transformers *V'A I�c+<9iPruf T•ub. SwfmmiIIg Pool r�b0 ve ❑ ❑ o.O Bey —•, No.of Receptacle Outlets No.of On Burners `� IIni� Na of SwitchesFm ALARMS No:of Zones • No.of Gas Burners o•• oa as No.of Ranges Na of Air CoI o In afing Beviees . No.of Waste Diapoaers ump Tons g DvAces Totafs: ow @• n No.of Dtahw sabersDevices- Space/Area Heating KW No.of Drgera Heatfgg,°1PPliaacea ❑ Connect[ou ❑Otho' o. star ICW tams: Heaters KW e.o o. No.of evim or Ufvalent �m No'age Bafhba No.of Motrts BalfaMa No ees or Utvatent Total HP eco ns OTHER.: No.of Devices or t EsNmatod Value of Electrical Wotic Attach adaYttoI'll al detail iIM jdesirBd or av„equiad by the I work to sty �"-/y/Z Ibs---- - m be men��by alP°l'�Z "SOT ojA 16URANCI COVUAGE: Unless waaved by �r �� ordsacc with MBC Rule 10,and upon compietioa. the liecasec,provides proof of liability iusmance inc PO1 for the P cc of clectticat work may,sane unleUMUTOPW ss oerbfies that such coverage is' "complated option'.'coveraas e4&itedge or its substantias equivateat. The CMECXONE: INSURANCE ❑ Proof of same to the permit WUing office. •feaft larder the pains and pia 0'perjmY t3T the R. 0 kspli . AVIMNAMM. . ,t W'=°10 on d*VW&AWOW arawaw'daosi Licensee:(Tapplicab LTC.NO- Address: r..fit"ta the license nurnbar line.) tUre LTC.NOi '' *Per M.Q.L c. 147,s..57-6I,security work Bps.TQl.No- �at the ant Public Safety"S"Lacel �Tet.No..' OWNER'S ECCE WAIVER: I am swam that the Licxasea does not have�l� • Lie.Na, requillmd by law. By my eiipMure below,T hereby waive dds Y i�uremc:e coverage normally S��/ eAgent T am the(checkone owner owner's T�PhoneNo. PERMITTEE:$ l . ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INSPECTION: Pawed—LZ Failed— Rllls on reqUired 550.00 Inspectors'co meats: rs' tare-no Initials Date 2.FINAL INSPECTION: Passed— Failed— Rafn ectlon ufred(SS0.00 _[ Inspecto ' mments: tors' nXre- Bala) Date 0tw 3.UNDER GROUND INSPECTION: Pastel—[ Failed—I I Rein on re aired($30.00)-I j r Inspectow comments: Okspectors'5 ature-no Inftlals) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed-- Famed-1 Inspectors'comments: R on aired($S►,00)-[ na ors'$ tnre- initials Date ,' 3.INSPECTION.OTHER: Passed—I I Failed—I Re-ins tion aired($50.001- Inspectors'comments: (Inspectors'Skusture-no inftials) Date DOOR TAGS ARE TO BE EUM g, AND LM ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF SS0.4Q 13 TO BE[�eRrn