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Date....... .......... ......
v ...o .
0�`� TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
`J
1
This certifies that ...J.X..`.................�%..-........................�.....................
has permission to perfo `�!a Y.! .y l ,1�� /......
wiring in the building of ..,:. .�%...........
:...:....�............................/... ,North And�ov�er,�M.a—ss.
Fee. .... L No. l"�lF..........r ..
�(% ��ELECTRiCAL INSPEC'I'ESR
Check # �N// / D, ,
-5433
Commonwealth of Massach
�d Department of Fire Servi
BOARD OF FIRE PREVENTION REG
APPLICATION FOR
All work to be performed in a
(PLEASE PRINT IN INK OR L
City or Town of:
By this application the undersigned gives not
Location (Street & Number)
},€g Official Use Only
i Permit No. cj
Occupancy and Fee Checked Y t
TIONS [Rev. 11/991 leave blank
IIT TO PERFORM ELECTRICAL WORK
with thassachusetts Electrical Code (MEC), 527 CMR 12.00
WATT N) Date: 62
To the Inspector of Wires:
o h r intention to perform the electrical work described below.
Owner or Tenant�[�/��-�j`
Owner's Address
Is this permit in conjunction with a Building permit?
Telephone No.
Yes. ❑ .No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: Installation of Security system
Completion of the following table may be waived by the Insnertor of Wirac
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
Swimming Pool Above In-
❑ rnd. ❑
i 0. mg
omergencyigrnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No.of Gas Burners
No. o Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons_
No. of Alerting Devices
g
No. of Waste Disposers -......
Heat Pump
I 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 Kit
Security Systems: 2
No. of Devices or Equivalent /3
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.
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:)
/a (Expiration Date)
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.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:ADT Security Services 1-a r1iAtAn My- Hn]liq �IH LIC. NO.: 1g3.q(-
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 Lid9fisee 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) E] owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
`x
Location�GO
; s
No. ✓ Date
�oRTof
TOWN OF NORTH ANDOVER
AL
9
Certificate of Occupancy $
Building/Frame Permit Fee $
.2 CMUSt
Foundation Permit Fee $
y
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $ y f
'i3457
G' Building Ins`pctor
Div. Public Works
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FORM U - LOT RELEASE 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 or requirements.
*****************APPLICANT FILLS OUT THIS SECTION
APPLICANT �h a pS ��ax-/- PHONE 17 1_-/6/b
LOCATION: Assessor's Map Number I QS C PARCEL 06
SUBDIVISION LOT (S) l q
STREET C d/ ST. NUMBER 2G
****************** ************OFFICIAL USE ONLY************************
RECOMMENDATIONS OF TOWN AGENTS: fy 5�&d x��
COMME
—0n �� -�
TOWN PLANNER
COMMENTS
ATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH
1
Y SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
W
7
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name: &x% -Les
Location:
City Q. 61 0 j o u , - Phone # 7.S
1 am a homeowner performing all work myself.
aI am a sole proprietor and have no one working in any capacity
aI am an employer providing workers' compensation for my employees working on this job.
Comoanv name:
Address
Phone
Insurance Co. Policy #
Com an name:
Address
City: Phone #:
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition or criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in tate form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a ccpy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify u de th painsandpenaltie of per' that the information provided above is true and correct.
Slg
nnri rA ��A fly �� .(� Date ���/���
Print
Phone # yJ —� /�✓
Official use only do not write in this area to be completed by city cr town official
City or Town Permit/Licensina
❑ Building Dept
❑Check if immediate response is required ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone #: ❑ Health Department
7 Other
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