The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 151 BOXFORD STREET 4/30/2018 (2) J / 151 BOXFORD STREET 210!106-A-0257-0000.0 �f I i I I zMW• Ae 8. In accordance with the provisio,s of '-M.G.L. c. 143 § 3L, the permit applica- tion form to provide notice of installation of wiring shall be uniform throughout the Conunonwealth, and applications shall be filed on the rescribed form as a c. ef 4 a e tted o �r�es�b �o u - � ,o,- Lal• >o� G;; es, Date..y./Z-n!e.7...... NORTH °ft °:•�"� TOWN OF NORTH ANDOVER F 9 PERMIT FOR WIRING ,SSACMUS� � This certifies that ��C..�AAI L cT 4: has permission to perform ....Amz%:I!�?...../.....:l*,o j/ �% . ............... ....... �. wiring in the building of.................l`..v.T.......... ......................................... at . oXr�o�. North Andover Mass. Fee..2OS..�Lic.No.............. ....... .; *.. f�1 !........ ELECTRICALINSPECI R E 7 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 7 CMR 2.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: `-/2/71 O City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street& Number) 19-1 B ox�Jry Owner or Tenant Telephone No. Owner's Addressm_Q_ Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Si nSIQ ivy\, ( Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead F] Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: � � �, �� O v-, V,,'tcke \,N m�5�e c fiSeC) rn a--f `t�•S Sy c PC,� Completion of the followingtable tnaZ be waived by the Ins ector of Wires. No.of Recessed Luminaires `DLC) No.of Ceil.-Susp.(Paddle)Fans No.of ota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA i No.of Luminaires 1 Swimming Pool ove EJ ❑ o.o mergency ig ing rnd. rnd. Batter Units f No.of Receptacle Outlets 3S No.of Oil Burners FIRE ALARMS [No.of Zones No.of Switches No.of Gas Burners o•o etection an Initiating Devices No.of Ranges No.of Air Cond. TotalF Tons No.of Alerting Devices No. of Waste Disposers eat Pump I Number Tons KW No.of Self-Contained G Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unic'pa ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.o Water KW o.o o•o Data Wiring: Heaters Si ns Ballasts No.of Devices or E uivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecom municationsirmg: No.of Devices or E uivalent 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 complete. PP p FIRM NAMEP i C-a CIO , LIC. NO.: aQS-;;L0 fl Licensee: (,,,<, i CG cd i Signature� wt, �`r.�/�C_ LIC. NO.: 3RUOP E (If applicable, enter "exempt'in the license number line. l 3 7J Bus.Tel. No.: Address: I`1�(Cy � t`e (Zz GtJ 0S Alt.Tel. No.: ALY y-760/ *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 FE E: $ _97& 37-s ' -578 ern78 f-- 760/ RI'C4 crk5 tom -- i f � K 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): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑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. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers_' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation. 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: 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 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#: • ,; .� .�Y r Date , -�•�'•7 HORT/� .1� TOWN OF NORTH#ANDOVER � �: .�,� --•.�• °oma ,.� PERMIT FO-+' LUMBING S CHUS V This certifies that .. . . . . . . . . . . . . . . . . . • • has permission to perform . . . . .P co 14. C. . . . . . . . . . . . . . plumbing in the buildings of . . . .r ! . 7._. . . . . . . . . . . . . . . . . . . . . at . . ./: ./. . . .S3.o .x. . �'G. . . `. . . . . . . . . . , North Andover, Mass. � v c Fee.�. r. . .Lic. No.. ?: . .3. . .c PLU BING INSPECTOR Check # 7356 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ✓ 11� r Date Building Location �� 'GYU� �f Owners Name l�C4 Permit# 3✓ Amount Type of Occupancy New 0 Renovation 1.1.x' Replacement El Plans Submitted Yes El No 1 FIXTURES rA a rZ y, a a H . A004 d SL18ME ISI:FUM zD FERR 3M FUM 4M FUM 5MROM 61H FLOOR 7IH FIi.OQt SIH FI fm (Print or type) �� G G J Check one: Certificate Installing Company Name J!/C r ` [I Corp. Address LU 7 Partner. Business Telephone 2 13—IFIm/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 El Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 an ,Ya11 'ons un P it Issued for this application will be in compliance with all pertinent provisions of the M us tate g e Chapter 142 of the General Laws. r , By: Signatuir-olExensecuriurnDer Type of Plumbing License Title City/Town ►cense um'n�F- Master Joumeyman APPROVED(OFFICE USE ONLY ❑