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HomeMy WebLinkAboutMiscellaneous - 200 RALEIGH TAVERN LANE 4/30/2018 (2)6 'O\ 0 Date ....1... w°Z..-.'........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. .............................................................. has permission to perform ......:.P.. .�................ .: ......................................... . `� wiring in the building of .? !!g.iMo J— n ........................................................................ ZOO- �.v Q .. , North Andover Mass. at ..................................... .................. t�..�....... Lic. No.��1'�3.. ......... '.� ELECTRICAL INS¢�CTOR � ;.� Check # ���� fi 3; :2 10771 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. - 077/ 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 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) ad -a /�G1��t Owner or Tenant O� (�jy ;w Telephone No. Owner's Address ��a.v Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building re, S . Utility Authorization No. Existing Service Amps / Q 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: Attach additional detail f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 4-13, 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 h BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and p� alties ofperjury, that the information on this application is true and cooiplete. FIRM NAME: '` . fA : —v -lell (,o:.,-, U CEJ LIC. NO.• 1� Y l� Licensee: g,�Aaiic'y_. Ftlg-ey Signature ,�­- LIC. NO.: ' (If applicable, enter `exempt" in the license number line.) Bus. Tel. No.; , to Address: Alt. Tel. No.: &Q55, 2007 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'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. $ .., ,r w ",e aaoWin iaox m oe waivea o the[ns ector o Wires. No. of Recessed Luminaires No. of Ceff. 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- -No—.01 EmergencyTI-giffing rnd. ernd. Baftery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. Initiatingesti Dead vices No. of Ranges No. ofAir Cond. Tons Total No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW.... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No, of Dryers Heating Appliances KW Security Systems:*. No. of Water No. of No. of No.. of Devices or E uivalent KW Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 4-13, 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 h BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and p� alties ofperjury, that the information on this application is true and cooiplete. FIRM NAME: '` . fA : —v -lell (,o:.,-, U CEJ LIC. NO.• 1� Y l� Licensee: g,�Aaiic'y_. Ftlg-ey Signature ,�­- LIC. NO.: ' (If applicable, enter `exempt" in the license number line.) Bus. Tel. No.; , to Address: Alt. Tel. No.: &Q55, 2007 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'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.ao�r.n�SPCTxoN; s Passed---[ ] +'ailed--[ ] Ae-inspectionxesluiurecY($50.00)�r j .Inspectors' coinxneJufs: _ S y R• (Ing ectors' Signature -• no ?initials) Date 2• PEvM NSPAC ION; )Passed-- Failed -j ] � Re-huspection required ($50.00) •- [ � Inspectors' comments: (Cn.sl ctors'.9igna -no initials) Date ' 3, TTt4T yii Gp o Dm INSPECTION. - Passed -- (] Failed—[ Re-iusp eetion required ($50.00) - [ J hspectors' comments: (inspectors' uignatuxe •- no initials) Date �. WSPECTION-- O MR.' Vassed •— r palled [ )- Atte-inspeciion required ($50.00) [ J Inspectors' con_tm.ents: QhSp ectors' Signature •• no initials) Date I➢®OR TAGS .APX TO BE :FILLED OUT.AND LEFT ON SITE IU THE.AREA. T'O BE I SPECTED IS NOT .ACCESSIBLE ANA A. REWSPECTION OF $50,0018 TO BE CMRGED. _ The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations y 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /j ( Please Print Legibly -A Name (Business/Organization/Individual): : SI -Ir 1 �' ��_-Q Address: City/State/Zip: f( O )-c I�tRtnti �� 6- Phone #: 603 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).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. 05- We area corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have .no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. E] Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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 aie 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. �, — k " 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 uner i pais a p ies ofperjury that the information provided above (jis true and correct. Phone #: 6,o3 g66 G- (F 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 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 producedacceptable 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-contractor(s) 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeX. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727'7749 www.mass,gov{dia Location 9b0 a m t �t � �� � b -1 - No. (, ri f Date %' v I `� ' CD �oRTM 1h TOWN OF NORTH ANDOVER Gf..ao .a Certificate Occupancy $ of cHusEt� Building/Frame Permit Fee $ S Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 02 Check # 15639 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO ]FAMILY DWELLING r 0., - BUILDING PERNUT NUMBER: DATE ISSUED: SIGNATURE: Building ColnmissioneEIRERwtor of Buildings Date SECTION SITE INFORMATION 1.1 operty Address: Z©Ci -inTA4�j (Y7`4— 19'i ` 1.2 Assessors Map and Parcel Number: / L�,,-' Map N � Parcel Number IJf— 1.3 Zoning Information:`^ Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Regpired Provide Required Provided Required Provided 1.7 Water Supply M.G.LCAO. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System Municipal ❑ On Site Disposal System. ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.10 of Record -i, o` F�� (6-f( l Name (Print) Address for Service 5 -7z �� _a � - ( L� Sign Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature y Telephone Not Applicable (� License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone ou M Z O Q m O z M 90 O r Q M r r z G) t SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted.with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check a91 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: c -'n SECTION 6 - ES AT CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be r Q�,y ITSE3I�T1,y,�� a Completed b nru a licant �i 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Z.SO Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRAnCTOyR�APPLIES FOR BUILDING PERMIT I, (l l7U K lJ►-1 �� as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in a a je to work -authorized by this building permit application. f Si iaature of Owner Date T SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T11VIBERS 1' 2 ND 3 f SPAN ' DIMENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERLAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE, r� FORM U - LOT RELEASE FORMS IXC INSTRUCTIONS: This form is used to verify that all necessary a t Boards and Departments having jurisdiction have been obtain. This does no relie its from the applicant and/or landowner from compliance with any applicable or requirements.Ve ****************************APPLICANT FILLS OUT THIS SECTION *********************** APPLICANT_ v PHONE q LOCATION: Assessor's Map Number / L • G PARCEL j l SUBDIVISION ,�, LOT (S) STREET p- L2(6fit I /wZF' ST. NUMBER ZOO *****************************************OFFICIAL USE ONLY*********************************** ENDATIONS OF TOWN AGENTS: CONSERVATION ADM COMMENTS TOWN PLANNER COMMENTS FOOD--INSPECTOR-HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm O \(— PUBLIC L DATE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL (FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: ,f -Q f ou-- LYC= V= (Location of Facility) Signature of Permit Applicant I3102 - Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax Please print DATE�3 �62 JOB LOCATION "HOMEOWNER Number Name HOMEOWNER LICENSE EXEMPTION TAW Fri Street Address Home Phone PRESENT MAILING ADDRESS 610 City Town Mate Cow1Map / lot - Work Phc�nc. Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) .DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures_ A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNAiUR APPROVAL OF BUILDING OFFIC The Home Depot #2663, 92 NEWBURY ST, DANVERS, MA 01923, (978) 7 .S�in Jun 02 10:01:50 2002 File saved as: f:\dn\decks\60208CE4.DEK Deck Dimensions for Deck 1 Railpost Spacing = 96 in. o.c., Baluster Spacing = 3 in., Toe Spacing = 3 in., Railing Height = Stair 1: Rise = 7 in., Run = 11 in. The Home Depot #2663, 92 NEWBURY ST, DANVERS, MA 01923, (978) 7 Sun Jun 02 10:01:50 2002 The materials in this deck will cost $121923.92 File saved as: f:\dn\decks\60208CE4.DEK 3D View The Home Depot #2663, 92 NEWBURY ST, DANVERS, MA 01923, (978) 7 SLiii Jun 02 10:01:50 2002 File saved as: f:\dn\decks\60208CE4.DEK Post Layout for Deck 1 12' 2' 1' 3' BasePc 00 12' 2" P 3" N Ln int 12' 2" P 3" � O• F;3e�E� t ' Ili m M T r 1 G MORTGAGE INSPECTION PLAN for mortgage purposes only "Mat If a m a u 4e GFe-K' 2 g�•o�K vJ.t^•p• ASC File # IC -6c.1 'Certification is hereby made to CITY OR TOWN flor�-rt-� Q�t po�;F 'Tt-1 � LAW O Fr— t ce= o V ,4�,"T VA®,4 --- � e , MA Ccr Ass t . DATE= OF INSPECTION: that the existing structures shown on this plan are situated on the lot designated in compliance with the setback requirements of the applicable zoning bylaws SCALE: 1 inch of the municipality when constructed, or are exempt from violation enforcement action under M.G.L. Title DEED AND PLAN REFERENCE: Vll, Chapter 40A, Section 7. _ s e:x �t Registry of Deeds 'COMIcation Is hereby made that the existing dwelling or principal structure shown on this plan 1•" ✓ls not situated within a Special Flood Hazard Area 2. is situated within a Special Flood Hazard Area 3. Information Is Insufficient to make determination. An elevation survey is advised. as delineated on the FIRM FI Insurance Rate Map Community No: 25oo48 000e,� Effective Date: G /Z Deed Book 1, 6 Page.:4F 85!3 __1I_G Plan Book Plan •GENERAL. NOTES: A confirmatory survey is advised when structures are shown to be situated at 1 foot or less from Property lines or required setback lines, or when potential encroachments are noted. No responsibility is herein extended to the property owner or occupant. Certifications and representations are on the basis Of my knowledge, information and belief. "'inori' ALPHA ""'n°�< '. SURVEY CORPORATION ' 126a Pleasant Valley St. - Suite 7 -Methuen. MA 01134.4 Received T i m e'A p r • 18 . 2 2 4 P M Telephone (978) 975-5100 - Facsimile (9781 u7r,-n, qK OFFICIAL INSPECTION FORAW —RIOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-1111SPOS(AL SYST$M INSPECTION FORM FARTC SYSTEM7,W0RMA7I0N (cont➢traed) Property Addrm: awneu:•�J Data "lnspection: SKETII;H OF S$ WAGE DISPOSAL SYSTEM Provldri a slrotch of the sawap disposrl sysmm incluftS ties to u least two benchefts. Lom all wells within 100 foez. Locs2e w>sere ppblic water pj re emm l��l`s ear XuPP Y CUM tt building. 1 I . i OT 39dd TT02 r hl-ld3N -IVAO ! M 0VND/u0S1HVD I o5vL9898L6 Zb:cT Z©©Z/ZT/Elo 00659898L6 YVd 9T:5T 21111 ZO/ZT/V0 U) m m m VJ Cl) 0 CA a Z CD O CL O .0 0 o p a� Q co 0 Q 0 co co CA 'O CD .0-� O �J CA .O O O CA F O C y n co 0 r� CD a rX. CD C+4) 0 CCD O C CD cn rD cn o77* tp C O C ?� O d ca mm w �' o rD —• cr N _a.oea O m p m Cl) 0 aGa °�'� n 0 y Cl) C1 n CD cn ^ o d Z go �m o = Mn =rm =rN NCD o m : 7 a -11 !R O `) Wo O o, C �y:�:A/ 06 o d y C N m r ^ V J `fA Q N O CD A/ Pf O m : O � O Q :o CD oCD 0 a .p•� =r m P. `• _ CD cacn CDI �Lo Co d d� o o: cl :S c = Z G cn rD cn o77* tp m 9y o mm w �' o Cil w 0 aGa °�'� n 7d oGa -n 0 0. o cn ^ o d r/ A l2 y 0 0 c „ZZ L � 1 Date ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......................!�... /.....1 F.C........:,�..��....................... has permission to perform....................................................................... wiring in the building of .........�. ..... � ..(....... l ...................................... r CJS ri r{ 1 { � �`. ;l. North Andover, M s!. J Fee .... .).. ? .......... Lic. No ::......... ............... /' �e.... ..:%.......... ELECTRICALINSPE60R Check # /” / ' �/ r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only C1-1 CY Permit No. 3 a 9222 Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 CM 12.00 (PLEASE PRINT IN INK OR TYPE AL INF ATION) Date: ") _ City or Town of:AA To the Inspe or of ires. By this application the undersigneA g�es not of l is or her �,ntentionn to perform th7 electrical work described below. Location (Street & N er)llas&m affif, -q Owner or Tenant I Telephone No. �,P 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 New Service Amps / Volts Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters 1 Location and Nature of Proposed Electrical Work: Installation of Security system Completion of the followin table maybe waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures AboveIn- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency ig ing Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kit Security Systems: No. of Devices or Equivalent No. of Water Kit Heaters No. of No. of Signs Ballasts Data Wiring: 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. 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:) _ (Expiration Date) Estimated Value of El ctrical Work: (When required by municipal policy.) Work to Start: O; Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains Andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:LIC. NO.: Licensee: John S. Bassett Signature LIC. NO.: 1533C (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 603 594 5928 Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Lid, see 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: $ N