HomeMy WebLinkAboutMiscellaneous - 21 SPRUCE STREET 4/30/20181r N° 3 L'. ' Date ...................
°:<``° TOWN OF NORTH ANDOVER
100 p PERMIT FOR WIRING
Thiscertifies that.....................:.............................'.........:.............. ..........
9�.............tt� has permission to perform ..:............:......-.. r ..............:.:...:..... .....,..........
f wiring in the building of
at..................................................... ...... ..................... , North Andover, Mass.
Fee ............ Lic. No.... ..:.:� ............... .....................
...... .....
ELECTRICAL INSPECTOR
Check N
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
TBE 00A MONWE40HOFMA "CHUSETIN Office Use only
7
DEPARTMFVTOFPUBLICSAFETY Permit No.�`�L
UAPPUCATION
BOARD OFMEPREVEN170NREGUL4T10AN527GVR 1200
Occupancy &Fees Checked PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat �f
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) C>/
Owner or Tenant 7`0
w YII I
Owner's Address i
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes [13'No M (Check Appropriate Box)
Purpose of Building
Existing Service Amps /�Volts
New Service +� Amps / Volts
Overhead Underground
Overhead Underground
Utility Authorization No.
No. of Meters
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work aR,117 J4Q 111 C/( , --7
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Tota
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
ground
E3
Rround
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
lo. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER
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FIRM NAME _N
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OWNER'S INSURANCE WAIVMl am awatethatftlx aisedl
a ndflatmysgttatisecnthispem*apphcafim tttism4m tx t
(Please check one) Owner M Agent
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as ta#WbyMassadxseus Gaiaral Laws
Telephone No. PERMIT FEE $ C;,�.
Location -^� -�--�-
Date A
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Chick #
N
Building Inspector
�1-I 610 3 3, o - ca►r�; ^moo, o ner�
TOWN OF NORTH ANDOVER
' BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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BUILDING PERMIT NUMBER: DATE ISSUED: 0 O
r .
SIGNATURE:
Building CorninissiMErns
j4ctor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
'�► t.' (PkycrC 57
✓
Oe/t-
Map Number Parcel Number
A A60G
1.3 Zoning Information Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.GL.C.40. 5 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHW THORIZED AGENT
2.1 of Record
Owner
r %L/ C O W x g—w a-- l S02,tyCA-
Name (Print) Address for Service:
rl/A- L V . 1-4 /V Z4-
"
Signa re Telephone 6? 8 �_
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
11,41Z .
Licensed Construction Supervisor:
q /�}� xgg " 97- AK-V��oof /zy�A '
License Number
Addr s
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
N ky lsmcL�,d ly"y C�rS 1ciN i�/LS/�Gvc/
Company Name
/ f 0t 20, GL SI a
2•C[ t L✓/ Z i1% 4o,
g Re istration Number
Add r ss
`0 ���
Expiration Date
Signature Telephone
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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 .......❑ No ....... ❑
SECTION 5 Descri tion of Proposed Work(check all applicable)
New Construction ❑
Existing Building ❑<e—pair(s)
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑ -
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work: q
Itie��-�C 1/—ec, L sl �> ori- %� 14'
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
t3FFICIAk USE}1�f(
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,—A A/ G'-�� ice/ , as Owner/ uthorized Ag t of subject property
Hereby authorize Z/f to act on
My behalf, in411411attersTelative to work authorized by this building permit application.
Si nature of bwner Date
SECTION 7b OWNER(/AjUTHORIZED AGENT DECLARATION
tA- ,as O er/Authorized n 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
r—�
Print N
Si ature � er/A Date mmammumam
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIIVIBERS 1ST 2 ND3 RD
SPAN
DIMENSIONS OF SII LS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
y
Ai i
Name: mg
Location:
City /c ly o Phone
F-1 am a homeowner performing all work myself.
F�I am a sole proprietor and have no one working in any capacity
®I am an employer providing workers' compensation for my employees working on this job.
Company name:S%6i-4i'
Address"_�� L Q Azz"eic— s l
City: I , L i'lil Phone #. 9 79 961
Insurance Co. Policy #% -7d
Company name:
Address
City: Phone #:
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature WDate % - 3
Print name Phone # 48g/
Official use only do not write in this area to be completed by city or town official'
❑Check d immediate response is required
Building Dept
Contact person: phone
FORM WORKMAN'S COMPENSATION
❑
Building Dept
❑
Licensing Board
❑
Selectman's Office
❑
Health Department
❑
Other
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:
(Location of Facility)
kw
nat Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
16
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