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Home My WebLink AboutMiscellaneous - 153 ACADEMY ROAD 4/30/2018 , t � �- --- Location No. Date �a ' MOATM TOWN OF NORTH ANDOVER iy 4, il ; , Certificate of Occupancy $ 'Ss�cNusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 24 4 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION i 5 3 AC� A P E*_,n 'Rb A#JZS?ye-- Print PROPERTY OWNER N A 1A 15T• S-o C,.1 Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no n-4- Machine Shop Villa g no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Z� G(_QT' &o4FZ® C-� MP' Z4, w '%� �/11R, i�.cPLbIt, 16 Yf (Identification Please Type or Print Clearly) OWNER: Name: )�).A - I�1 S T e V-\L n L So C— • Phone: 57 ff 6 8.6 4 0 3 5 Address: 15 3 Ac-AQe_ �D IJv PNP4p-0y-e.P, CONTRACTOR Name: J �, 0 W h Ir 5_D#1J Phone: 17a 6(- `1 ,3 S /D Address: ov (y I 3 sic c xi � �EA D s l.�L 0A.4 O Supervisor's Construction License: z Z_ � D1� Exp. Date: 3 2 Z 11 Home Improvement License: i o�j q 3 Exp. Date: i Z0 1 Z, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ I �l z 5 O FEE: $ Check No.: � Receipt No.:a ,(f 3 z�, NOTE: Persons contracting with unregistered contractors do not have access to guaranty fund W , - Signature.of Agent/Owner Signature of contractor i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ElSwimming Pools El j Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS µ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS E Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi J Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits I ❑ Building Permit Application o Workers Comp Affidavit o Photo Copy of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks o Building Permit Application o Certified Surveyed Plot Plan 1 ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi NORTH Town of Andover . o , dover, Mass.,v Z • COCMICMEWICK 7�ADRATED P`? �S BOARD OF HEALTH Food/Kitchen PERMI D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... ........:. .. .. �. .tip.`... .... ... .... ........................... ................ Foundation has permission to orRe* t............::.......................... buildings on ....1..�I........ ... .. �!�,....... �............ Rough L to be occupied as... ...C.. . .: .... O.A. .............C' .......................... Chimney C e provided that the person accepting this pbrmit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONS ELECTRICAL INSPECTOR UNLESS LESS CONS 1 R C S Rough ................ .......................................................................... Service ................. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do- Not Remove Final No Lathing or Dry Wall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. i 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 LeLibly Name (Business/Organization/Individual): Jin ,� �,� j'c O PJ Address:_ s DA 557 F a City/State/Zip: 0,z, G d iJ ,ti G IMG Phone#: cl Are you an employer?Check the appropriate box: Type of project(required): [2. .❑ I am a employer with 4. ❑ I am a general contractor and I mployees(full and/orpart-time).* have hired the sub-contractors 6 El New construction loam a sole proprietor or partner- listed on the attached shget. $ 7• E]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 ME]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' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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: _`� AC/ n,p i+� �p City/State/Zip:�o 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 certi y unifer the pains 11and pen Ities ofperjury that the information provided above is true and correct. Signature: W Date: k Phone#: CI G6 4 rj 5'1 L R :7 59 D Z— Official use only. Do not write in this area,to be completed by city or town official. City or Town: Per # 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy;please call the Department at the number listed below. Self-insured companies should enter their .self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Comn-Lonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAIIE Revised 5-26-OS Fax##617--727-7749 www.mass.gov/dia NORTH 0 0Andover No. o , dover, Mass.,`J' Y Q - LAKE 1, COCHICHEWICK 7�S RATED BOARD OF HEALTH Food/Kitchen PERMIT .T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... .,..a........ ... .... .... .... ........................... ................ Foundation has permission to or t............::.......................... buildings on ....III........ ... .. . ... ......U.A........... Rough �.�.: .... a.�►. ............. Ct ....................................... t0 b8 occupied aS... .. . Chimney provided that the persoaccepting this p rmit shall in every respect conform toerms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONS ELECTRICAL INSPECTOR UNLESS CONSTRUC S ALTS Rough ................. ................. .......................................................................... Service BUILDING INSPECTOR Final U Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do- Not Remove Final No Lathing or Dry Wall To Be Done FIRE.DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. � 4 -tJ 4 .° ess ega a iu 1 icense or registration valid for lndivtdul use only HOME IMPROVEMrzNT CONTRACTORe - i be€ore the expiration date. If found return to: Itegistr�rtion: . 110493 ' Office of Consumer Affsirs and Business.Regulation -" Expiratiod 10(20/2012• Pr Corp4 ail t 10 Park Plaza-Suite 5170 Boston,NSA 02116 i G C C11R,ENTEIk tNC}- r JQHN WATSON ...T3 EDGEMERE RD Y (_ N.READING,MA 01&64 iJndersecktary'i Not valid without signature t►'i[.Ls at ht�set#�- Departn ent of Pub4c Safct► Board of Ruildino RegulatiOns and StnndU'ci Construction Supenelsor License License: CS 22409 R#rtrkted to: OD JOHN H WATSON EDGEMERE RDIPO'BOX 414_ w, N READING,'MA 01864 l'; n Expiration: 9F22=19 ("un�inin siinir TO$: 3803 • financially insecure. Contractor's Financial Insecurity-In instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal from said account would require the signatures of both parties. THE CONTRACT MUST ALSO CONTAIN: 1)A Complete Description of any other documents which are part of the agreement; 2)A List and Description of other matters upon which the contractor and homeowner lawfully agree; 3)Any Other Provisions otherwise required by applicable laws of the Commonwealth. Remember,the Contract must be the Complete Agreement between the contractor and the homeowner. If you have general questions or need additional information about The Home Improvement Contractor Law,contact: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170 Boston,MA 02116 617-973-8787 If you have questions about Contractor Registration,contact: Director of Home improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place,Room 1301 Boston,MA 02108 617-727-3200,x25205 I i I i include details of the alleged defect that permit Contractor to identify the location and nature of the problem;and (c) any repair or replacement performed by Owner, or any person or entity other than Contractor, will void this warranty, except in an emergency situation when Contractor is unable to be reached after reasonable effort. The contractor's liability under this warranty is limited to the repair or replacement, at the contractor's sole option, of the warrantied work. The above warranty shall be in lieu of all other warranties,express or implied,including any implied warranty of merchantability or fitness for a particular purpose. Under no circumstances shall the contractor be liable for any consequential damages, loss of profits or other direct or indirect costs,expenses,losses or damages arising out of defects in the work or failures of materials or other property provided hereunder. Exclusion of Consequential Damages. In no event shall either party be liable to the other for punitive or consequential damages, even if it has been advised of the possibility of the same. NOTE:All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration One Ashburton Place,Room 1301 Boston,MA 02108 61.7-727-8598 ARBITRATION The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration as provided in M.G.L.c.142A. Hom er's Signature Date Date Homeowner's Signature Date Date Homeowner's Signature Date NOTICE:THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR.THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. ACCELERATION OF PAYMENT Homeowner's Financial Insecurity-A Contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be Owner shall not have possession of the Work until such time as all Installments or other obligations required by this Agreement have been fully paid or performed by Owner. If the Owner takes possession of the Work before the Owner meets its obligations, then the Owner shall have deemed to have accepted the Work, as complete and satisfactory. In order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins(*Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total labor contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the ion schedule*):$to be paid for. O NO SI THIS ONTRACT IF THERE ARE ANY BLANK SPACES Identic op' o e co ct s Id go to the homeowner and the contractor. I Ho owners ature ate Date i You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or branch thereof,provided you notify the seller in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of the agreement. See attached notice of cancellation for an explanation of this right. REQUIRED PERMITS jThe following building permits are required.It is the obligation of the contractor to secure such permits as the homeowner's agent:List any and all necessary construction-related permits.General Rehab NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A. **All terms of the warranty must be attached to the contract** Limited Warranty. Except for equipment or materials that are warranted by a manufacturer's separate certificate of warranty,Contractor warrants that,upon invoicing of the final Installment,the Work will conform to the Work Description and will be free from defects in materials and workmanship for a period of one(1)year(the"Limited Warranty"and the"Warranty Period"). The Warranty Period shall begin upon the earlier of(i)Owner's final and full payment of the Contract Price,and(ii)the date on which the final Installment becomes due and payable. Should any defect appear during the Warranty Period,the Contractor will,at its option,either repair or replace the same,without charge to the Owner. The Limited Warranty is subject to each of the following conditions: (a) the Work is reasonably maintained by the Owner; (b) the Owner notifies the Contractor in writing within thirty(30)days of the discovery of any defect,such notice to any improvements other than as specifically stated in the Work Description. Clean-Up. Prior to invoicing the Owner for the final Installment, the Contractor shall remove all trash, rubbish, debris, boxes, wrappings, etc. generated in connection with the Work, and all of the Contractor's equipment, as well as any leftover materials and inventory from the Property. Change Orders. The Owner may propose changes in the Work and any corresponding additions,deletions or other revisions of the Work Description,Contract Price,Installments and Completion Date. Any changes shall be authorized through a written change order signed by both the Owner and Contractor. See Attachment for Materials Expected To Be Used:(Additional Materials not listed will be billed accordingly) New#1 vertical grain red cedar primed clapboards,stainless steel nails This material list is just an estimate,additional,or less supplies maybe necessary,prices are subject to change with the market,quality and design. BTD does not mark up the materials,and prefers customers to set up credit card account. The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Work Scheduled To Begin Expected Date Of Completion (weather permiting) 0L z_01 ) - $�driiS�2pi 1 TOTAL CONTRACT PRICE AND PAYMNT SCHEDULE The Contractor agrees to perform the work,furnish the material and labor specified above for the SUM of: $14,250 ' Payments will be made according to the following SCHEDULE: 33% upon signing contract 33% upon completion of half project Balance upon completion The Contractor will deliver an invoice to Owner for each of the Installments. Within ten (10) days of receipt of any invoice. Owner shall deliver written notice to Contractor detailing any reasons why any Work does not conform with the Work Description ("The Objection"). Payment of an Installment by Owner or failure to deliver a timely Objection, are each acknowledgement that the Installment is properly due and payable. The Owner shall pay Contractor interest at the rate of 1.5% per month on any Installment not paid on the due date, or if not specified, within thirty (30) days the invoice date. If the Owner states an Objection, then the Contractor shall have thirty (30) days to use reasonable efforts to remedy the matters stated in the Objection so that the Work conforms to the Work Description. The Owner shall again inspect the Work within ten (10) days of written notice by Contractor to Owner that the matters stated in the Objection have been addressed where applicable. If the Owner again states a timely Objection, the Contractor shall have a second thirty (30) day period to use reasonable efforts to address the Objection. Any statement by Owner of a baseless objection shall be deemed a breach of this Agreement. r F y l' t 1( 3 MASSACHUSETTS HOME IMPROVEMENT � CONTRACT � This CONTRACT satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL c. 142A), but does not preclude parties from adding language to protect their specific interests. Seek legal advice If necessary. Before agreeing to any home improvement work on your residence You should obtain a free copy "A Consumer Guide to Home Improvement Contractor Law" by calling the Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787. Homeowner Information i North Andover Historical Society Attn: Carol Majahad 153 Academy Road North Andover,MA 01845 Phone 978-686-4035 Mailing Address(If Different From Above) I i Contractor Information John H.Watson dba The Gothic Carpenter 3 Essex Street PO Box 414 North Reading,MA 01864 Business Phone 978-664-3510 Federal Employer tD 031-34-8890 Contractor Registration#: Exp.Date: l � z.z. /r N'� l ��y 5 3 1 Ln � Z i WORK TO BE PERFORMED AND MATEIMA TO BE USED Contractor Agrees To Do The Following Work For Homeowner and contractor will be responsible for pulling appropriate permits: Project Description: Clapboard replacement/trim repair of Museum complex Handwritten Notes: The following items are not included in this estimate,and would require a change order: Asbestos Any rot that is discovered may require replacement,the scope of this is impossible to predict and therefore sal, not included in this estimate. Thank you for your trust and confidence. + All materials,electricians and laborers necessary to complete the above description are included in the price. The Owner and the Contractor agree that the Work Description cover all items of work, labor, and materials needed for the remodeling and/or construction of improvements and appurtenances on the Property and that Contractor is not responsible for furnishing Dat ............................... NoarM TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS 7 This certifies that ........... ....Dew......�.4�F GT .................... ................. ... has permission to perform ........................ .................. wiringin the building of................................................................._0.............. at.......... U��..... A2.............0 ,North Andover,Mass. Fee... Lic.No. J/.�q. ........... tSLECTRICAL MR -I Check # 3 P'7P 7907 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No.-- 62 �7 — Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR .00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ' 'Z. Z 1 0 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)(j 3 Owner or Tenant -(�-7—c— Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service L/CXR Amps /2e /Zye)Volts Overhead❑ Undgrd 0— No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: V� F— FEE C> L Ee- Se.l^yl'c-e Com let n o the ollowin tablem be waived b the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. 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 Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump TNumber Tons KW No.of Self-Contained otals: ..._ . .. ............................. .........._._.......... " Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.o Water No.of No.of KW Data Wirin Heaters Si ns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices or E uivalent OTHER: G (, 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( -$OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: /a roto re— C,rj-` LIC.NO.: C( Licensee: 6 t-P-0h.e� � Nr,rob-%p Signature /f �f LIC.NO.•A,J(�( (If applicable,enter'exempt"in the license numbgr line.) ^ Bus.Tel.No. 7 r - �al 7 Address: 10(5 W�ri( I�,e S P.� �Y`�- /J Alt.Tel.No. 7F//— CJ *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No OWN'ER'S INSURANCE WAIVER: I 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. $ z r w i s�-� 4