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HomeMy WebLinkAboutMiscellaneous - 202 ROSEMONT DRIVE 4/30/2018J O N lj � N � 0% -"o p m itRw0 o � o � o m 11592 Date......t t .. . ........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ............... ....> w This certifies that ...................... ...................................................... 'ha s:.Permission to perform .. ....... .... .............................................. plumbing in the buildings of ..... ............ at ..... 2-n2 . . .... .. . i4(3ith Andover, Mass. z5b Fee::e ..... Lic. No. ................ ...................................................................................... .............. ... PLUMBING INSPECTOR ChecIk SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES J'ATER PIPING INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Ej BOND Q 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 ONLY: OWNER E-11 AGENT 10i .SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I 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. ---N)_ PLUMBER'S NAME .__. LICENSE # (T SIGNATURE MP01 JP CORPORATION._PARTNERSHIP ®#= LLC COMPANY NAME '�if.Y'-(� �DDRESS CITY�� �-.iISTATE ��f'Y)li it ZIP � � TELL—OM -61440 FAXCELL I EMAIL 011 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY rl< MA DATE PERMIT # JOBSITE ADDRESS 2D2 < OWNER'S NAME ADDRESS �� TEL b�2 �1�� _ FAX OCCUPANCY TYPE COMMERCIAL EEDUCATIONAL © RESIDENTIAL NEW: O RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES ® NO FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE f ► �_ _[ -1i _, ,.M,Y; �__ ! I ! DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM _ 6 __._.__[ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM._...__...I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I -__J —_J _-__–_i ROOF DRAIN SHOWER STALL _f __-_-- fill SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES J'ATER PIPING INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Ej BOND Q 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 ONLY: OWNER E-11 AGENT 10i .SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I 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. ---N)_ PLUMBER'S NAME .__. LICENSE # (T SIGNATURE MP01 JP CORPORATION._PARTNERSHIP ®#= LLC COMPANY NAME '�if.Y'-(� �DDRESS CITY�� �-.iISTATE ��f'Y)li it ZIP � � TELL—OM -61440 FAXCELL I EMAIL 011 o rl z (n ❑ LU CL w W n 0 The Commonwealth of Massa chusetts M z Department of Industrial Alccidents 1 Congress Street, Suite 100 ' Boston, MM 02.X14-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: YY1Phone #: 9 i g 7iS,6 6L)6I Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with employees (full and/or part-time).* 7. ❑ New construction 2. a am sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Ele trical repairs or additions proprietors with no employees. 12: lumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ 13. FJ Roof repairs These sub -contractors have employees and have workers' comp. insurance.x 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑Other 152, § 1(4), and we have no. employees., [No workers' comp. insurance required.] `Any applicant that checks box #1 must also till out the section below snowing their workers' compensation policy mtormauon. i 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. xf the sub -contractors have employees,''Ihey must provide their workers' comp. policy number. I am an employer that is piovidiiig workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: e ST1e \ Z (au ,� �� :rC�r� / mci Policy # or Self -ins. Lie. #: 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 ofperjury that the information provided above is true and correct. Signature: ^� — ^' �- Date: 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 #: F� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their pmployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract o 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia ri 0 :o COMMONWEALTH OF MASSACHUSETTS PLUMBERS 'JkND GISF ITTERS ISSUES THE FOLLOWING `LICENSE LGEN DFAS` A JOURNEYMANPUUMBE' KEVIN_ C M} CDONALb' ' 2 E VA N S -WA'' .. {� � , W E"5Ex M 019 2 9 1160 �. 234 ;:.,05/0l/16.tf.,. 204568 LocationZ:��tt i�. 2-( A No. Daae °RT" 'TOWN OF NORTH .ANDOVER ,,•�•� ti goo 3 • fid. 4 Certificate of Occupancy $ Building/Frame Permit Fee $ .Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee _s $ TOTAL $ Building Inspector %d *� 14#):05 1,265.00 PAID ",ga Div. Public Works $2,82 zi Location No. - -2-1 L Date '5 12Z 1q9A Of N°RT" TOWN OF NORTH ANDOVER Certificate of Occupancy $ _29, Building/Frame Permit Fey; $ 0. D Foundation Permit Fee $ CXR Other Permit Fee $ Sewer Connection Fee $ i Water Connection Fee $_ .: TOTAL Building Inspector 8281 Div. Public Works . 3' ocation 74�-?%xr' j Date � :N NORTH TOWN OF'NORTH ANDOVER 3 p Certificate of Occupancy $ -� :. + i Building/Frame Permit Fee $ Foundation Permit Fee $ "'- �cMus Other Permit Fee $ .` Sewer Connection Fee $ 4t,5¢ water Connection Fee $ a43. 5o TOTAL $ 2� 43 f a - v � �ui9di g Inspector p +y Div. ubl dworks 8 3 'eo PER31IT NO. Z I'l APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 EMAP d40. LOT NO. I 2 RECORD OF OWNERSHIP DATE BOOK :PAGE ZONE SUB DIV. LOT NO. LOCATION 1 D16J'-T— D/�L\ F�� �11 ^f K`- IJIJ� V/l PURPOSE OF BUILDING -7 OWNER'S NAM OWNER'S ADDRESS ; / N STORIES /1 SIZE' "rw1ll BSLABASEME O L►� ARCHITECT'S NAME 25 BUILDER'S NAME ` �a.�/� - ZE OF FLOOR TIMBERS IST &,a 2ND �fYi 3RD �l�G SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET --- "' POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS /It AREA OF LOT 20FRONTAGE IS BUILDING NEW ,/> �iA HEIGHT OF FOUNDATION QW THICKNESSIt /� Y SIZE OF FOOTINGc� %- et /L IS BUILDING ADDITION �Y/V MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING SOLID R FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE / ` IS BUILDING C CTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY �.�/� IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE R PLANS MUST BE FILED AND APPROVED BY BUILDING -A DATE FILED J SIGNATURE SIGNATURE OF OWNER OR AUTHORIZED AGENT 7 F E E 13 (0S; c�CS PERMIT GRANTED -iE22 19 qs- PERMIT FOR FOUNDATION ONLY 3 PROPERTY INFORMATION REGULATED BY PARA. 114.8-S. B.C. LAND COST EST. BLDG. COST 2ot /bS" �•� EST. BLDG. COST PER SQ. FT.!9 / (S- �- DATE AFEE PAID ®� EST. BLDG. COST PER ROOM --i'j SEPTIC PERMIT NO. 4 APPROVED BY TIONS PERMR FOR FRAME/Bfl11LDl DAtE:jFEE PAID:L7d NUILDING OWNER TEL.# 6A:n2 CONTR. TEL. # 45F ' �/(�(�/ @ONTR. LIC. # 5y H.I.C. # 0= PERMIT FEE 3 S a3 -z' - C 1995 LESS FDA FEE �- SZ�b t -- ILDING RECORD ' ...... ... T z r. SINGLE FAMILY STORIES 7 '+ MULTI. FAMILY OFFICES 4. APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B 1 2 I3 CONCRETE BL'K. PINE BRICK OR STONE HARDW D _ PIERS PLASTER _ •' _ DRY WALL _ FIN UN BASEMENT s1 AREA FULL FIN. B'M'T' AREA '/. 1/3 1/ FIN. ATTIC AREA _ NO B M FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I .9 < �..: FLOORS CLAPBOARDS CONCRETE EARTH B 11 2 �_ 3 DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARDNWID COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK -,ON N MASONRY- BRICK ON FRAME ATTIC STIRS. & FLOOR _ CONIC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR COR _ ADEQUATE NONE -10 PLUMBING 5 ROOF GABLE HIP BATH (3 FIX.) GAMBRELAMANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR - TILE DADO 6 FRAMING 11 HEATING WOOD `JOIST` aAY, Ia PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. &'COLS. OT W'T'R OR VAPOR WOOD RAF/T _ AIR CONDITIONING ,QRS L 0 Y RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS CIL B'M'T 12nd I ELECTRIC THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT'AND DISTANCE -FROM f LOT. LINES AND 'EXACT DIMENSIONS OF BUILDINGS. , WITH PORCHES. GA- • RAGES; ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.. , 1P,«} �ivliHl II lt�. qP` ; 1 TTl.ljR" p; -,-i � T -. ,....._,.. a F E , „t Ist 3rd NO HEATING VIRUSu t.. v 5� 4. 1P,«} �ivliHl II lt�. qP` ; 1 TTl.ljR" p; -,-i � T -. ,....._,.. a F E , „t Ist 3rd NO HEATING VIRUSu t.. v I C to Z z N f/! z m 0 c CA Cl C o z=•-m C � oP." m N pr 97 = o a=d CD CA o � T y 'C n O D nZ CO3CSD r O 'C 01 CL r- �' o N n W m c =ro� MM C. Cz a S CD m = y m N m CD C 1 O m �C CL r - m N o v CD o m N d. CD C2. � d C-) CD 0 CD m t" t= C.O ER VF m = 0 CD y m G1 N�I CS o coCA C) �CD z — CO) � O ED � O Z O go O C) CD CD T z rn C c D r CD I m C/) C to CAQ O.o0.1m N f/! m C2 CO m c7 c CA Cl C o z=•-m N N -� oP." m N pr 97 = o a=d CD CA o � O CD a C r n 01 •D o N n W m c =ro� a S CD m m N m CD C 1 O m CL r - m N o m N d. Q d H m .rt IE m N rC 1 H NCD m G1 N�I a o coCA CD r c ca jjeJ, �V ED o go C) CD rn �Mo rn 2!; m CD o -fit - o m �O m m b z a' �;:2 0Fr } 4c .N.. � bo z c o 65 C> o = m C/) C to o c o " '� o '� C1 0 T -11 C o O ry N pr ? iil m T w O- C �• 0 ,, cp a o coCA r o M H 0 0 c 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 local or state law, regulations or requirements. ***************®*Applicant fills out this section***************** APPLICANT:�lfl.5 Phone LOCATION: Assessor's Map Number Parcel Subdivision J9�z'Ts Lot(s) % Street Wosfi/J wo. i?(ZUyu St. Number -26A ************************Official Use Only************************ RECOMMENDAT):ONS OF TO AGENTS: l A, Date Approved 5 � ( `,5- Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Food Inspector -Health lfiept�ic Inspector -Health Comments zz� e w -e- Date Approved Date Rejected Date Approved -!5-----1 1 q Date Rejected Public Works - sewer/water connections �J �� 9 -it- 95 - driveway per;it ld S l(—qs Fire Department "� 4 <6 - Received by Building Inspector Date VZ5 ill NOTE: ALL UTILITY LOCA71ONS ARE TO BE FIELD VERIFIED BY THE SITE CONTRACTOR. e05 TQ!.' Iri -� ,. f oduttuffliulw— LAND PLANNING wi EEdCMtMG k su t vEy 167 HART -PO" AVEN'UL 8LIJlNGHAX MA 02019 (508) POO -4130 FAX (508) 066-6054 GRADING / SrM PLAID W tm a LOT 21 NORTH ANDOVER ESTATES NORTH ANVOVM MA PWAM no 'CLL BROTHERS, INC. 16U0 wwT ram Dmn w2smOPtO, KA 01581 LOT ZO D L_ O T 21 20,797 S. F. ►.4 o, 4Z,t I i 1 47! AAT i o /J v/I-T -r'c = 3(,5. 93 28. Z t `O d m d 5 00 R,dSE1VE ( 5O' W IDE APP. 'WAY j SETBACKS : F - 20' S -D' R - 201 1 CERTIFY THAT THE STRUCTURE SHOWN IS LOCATED ON THE LOT AS SHOWN ON THIS PLAN AND THE LOCATION DOES CONFORM WITH THE FRONT, SIDE, AND REAR SETBACK REQUIREMENTS SET FORTH IN THE TOWN'S ZONING BYLAWS AT THE TIME OF CONSTRUCTION. I FURTHER CERTIFY THAT THE STRUCTURE IS NOT LOCATED IN THE SPECIAL 100 YEAR FLOOD HAZARD ZONE. THIS PLAN IS NOT TO BE USED FOR THE ESTABLISHMENT OF PROPERTY LINES, ERECTION OF FENCES, OR CONSTRUCTION OF ADDITIONAL STRUCTURES ON THE LOT. MAP NO.o006c COM NO.24V00% DATE: 6 -2-93 LOT ZZ BERNARD MUNRO SR. No. 34482 n FOUNDATION AS -BUILT torllm a: LOT 21 NORTH ANDOVER ESTATES NORTH ANDOVER, ALA r A= Poo TOLL BROTHERS, INC. 1800 VX3T PARK DRIVE •ZSMRD, KA 01591 I& LAND PLANNING =GIIiEEi m & wilm W7 Ealtl"= AvXm% lwmquiux lu omno (GN) Mo -4= M (eft) M&-"" �- C9 -95 I"= 40� NAE 21 9 q- 2-[t LrJ CO2 1!0 CD a = Cc) CD CL r- sm '0 CD CD CLCD cr %< CD C-) CD CD mcn M= M O< -0 m CL CO CD ELVA cm Cl) CD CD CD CD a cop)• CD CA CD cm 2m O CD :q CD CD cy W 5 -r -O a S-40 a cr =r go CA -4 2, CD C'13" 10CIO CD C-) > F- 5- am r co C" C/) O o so c= - 2". M= a U's g,j rn 0 31D 3C rn ~ , 04 Z "Mid wn o Z. co CD I'm 00) CO2 CA CD -440 40 --q 4t:b CD bo M CD i0o rr &J� EF 1 . i ragm, - � 54: 201-0 Cc (DIN C2 CD CD: CD CD >m W 5 -r -O a S-40 a cr =r go CA -4 2, CD C'13" 10CIO CD C-) > F- 5- am r co C" C/) m o so c= - 2". M= a U's g,j m rn ~ , 04 Z "Mid wn r- CD cm .1 co CD I'm 00) CO2 CA CD -440 40 --q 4t:b CD bo M CD i0o CD &J� C, •-- co CD :_� (DIN C2 CD CD: CD CD >m OQ C-1 C=or. 2, > F- 5- am r co C" C/) m pt o Go w a CLI CD CD .Cco , 04 Z "Mid ag r- CD cm .1 co 00) mc) CA CS, CD CD 4t:b CD bo M CD Co cz &J� (DIN C2 CD CD: CD CD >m OQ C-1 C=or. 2, > F- 5- co C" C/) C*l CD pt CD , 04 Z "Mid ag rn tz mc) CS, 4t:b CD bo M CD Co cz &J� L*l Rk, H 0 OQ C: > co C" C/) pt , 04 Z "Mid tz ell Rk, H 0 tt -.E U Office Use Only -� - 01he TIImmnnwralth If fflagscathunPn Permit No. i9paiimerit t]f'Publ-tt �afttu Occupancy A Fee Checked r 3/90 (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR :00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date q QK or Town of NORTH ANDOVER To the In ector Wires: The udersigned applies for a permit to p rform the sledical work described below. Location (Street &Number -�-�� Owner or Tenant Owner's Address ° Is this permit in conjunction ith a ullding oerniit: r Puroose of Building �/ Existing Service /y�y Amps _J —VO its l New Service ea�Jt"— Amps Z407 f>welloits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets I No. of Hot Tubs I No. of Lighting Fixtures Swimming Pool Yes No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrnd ❑ No. of Meters Qverhead ❑ Undgrnd u No. of Meters _�— Total No. of Transformers KVA Abover—, In- �- grnd. grnd. C Generators No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Eurners Battery Units KVA No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges y— I No. of Air Conc. tons Initiating Devices Sounding Devices Heat Total Total I No.of No. of Disoosals Pumcs Tons KW No. of No. of Self Contained No. of Dishwashers I Space/Area Heating _ KW T Detection/Sounding Devices Municipal C E; Other Local i 1 Connection No. of Dryers �� Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW I Signs Ballasts Wiring No, Hydro Massage Tubs / I No. of Motors Total HP OTHER: I _ INSURANCE COVERAGE: Pursuant to the requirements of Massacnuserts general Laws— I have a current Liability insurance Policy including Cempie Operations Coverage or its substantial equivalent. YES NO I have submitted valid proof of same to the Office. YES NO = If you have checked YES. please indicate the type of coverage by checking the appro ate box. INSURANCE BOND -- OTHER - (Please Specify) (Expiration Datel Estimated Value E! �(icaI W)rk S Work to Start 'A Inspec::on Date aecuested: Rough Final Signed under in P iii of p rjury: LIC. NO. FIRM NAME i NO. � LIC. ��yv) Licensee Sicnat (—ZZ Z�Bus. Tel. No. 5,,�, Address Alt. Tel. No. r O r o/ OWNER'S INSURANCE WAIVER: I am aware that the Lice noes not have the insurance coverage or its substantial equivalent as re quired by Massachusetts General Laws. ana that my signature on this permit application waives this requirement. Owner Agent (Please check one) e Teleonone No. PERMIT FEE S (Signature of Owner or Agent) x 55e5 !P Date .... -- r. 2502 NORTFf . ' j. °f TOWN OF NORTH ANDOVER - p PERMIT FOR WIRING Thiscertifies that ...... ar ......................./........:.............................................. has permission to perform ...l.... .........� ................ wiring in the building of ..... f .........f ! . K)—S..................................... at ....':: ;..1 JI ::.,...... ....................... , North Andover, Mass. Fe ..: O.j..0. Lic. No.,,.%"...%. -,/.Y�!' ............................................................. ELECTRICAL INSPECTOR f7 # j& `-- 08/24195 13:47 210.00 PAID WRITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File