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Date 3.10-Ki.11.3
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that.00L/Ue�0-1-4,,v C7-e--Pz,;,
......................... I ..................................................................................................
has pe rmission to perform .... 6T.�11.-A44 . .....
a .................. 7 ...
7
wiring in the building of ....... ..............................................
at.2/6 ......... W-Ursr 11-Y-.4 ..... ........................... . North LA,,,rn*fder,, Mass.
Fee
.......... 4 ...... ..........................
sWCrOR
... .... .... Lic. No.
'�heck #
11482
< LIN\ Commonwealth of Massachusetts
V
I Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. / /Y r2-, -
Occupancy and Fee Checked
Lev. 1/07] (leave blanIc
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12-00
(PLEASE PRINT IN INK OR TYPEALL INFORM TION) 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)2/ti a2d—ss A uc
Tele hone No./ 9�V07 3 Yl
Owner or Tenant Am.1pq h &I S 06)- p - I
Owner's Address _C/91W
Is this permit in conjunction with a building permit?
Yes n No E5 (Check Appropriat e Box)
Purpose of Building CS - Utility AutflorizationNo. -1 —
Existing Service _LgD Amps Id�J1Q.StO Volts Overhead Undgrd D No. of Meters
New Service _LQ_o Amps Lao / 2 YO Volts Overhead Undgrd [J No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
V4
i�� ipt;A" ofthe MlInwinamh7p may he waivedby the Inspector of Wires.
Atrach adaiiionai detall IJ Uvall k�% U1 "a I -J V ...
Estimated Value of Electrical Work: JZO (When required by municipal policy.)
Work to Start: in�p"ections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCIE —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 operatioif 'coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing Pffice.
CBEcK oNE: INSLTR-ANCEE] BONDEI OTBEREI (Specify:)
Icerfify, unde il . s andpenaltieslofpe * ry, that the information on this application is true and complete. r7bJ
r lep - LIC. NO.:
FIRMNAME` (C
Licensee: &L-140 J M Signature LIC. NO.: 6.1
f ap al znl,he Wense number line) Bus. Tel. No.:_b9L_—'_
"c
d P Alt. Tel,
�d s .L JU, Lic. No.
Per rMG 6 1, security work requires Department of Public Safety "S" Lieense:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredbylaw. By my signature below, I hereby waive this requirement. lamthe(C e e) D owner owner�,,S�ent.
Owner/Agent ERMIT FEE:
Signature Telephone No. EP
No. 5Y, otal
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
Transformers KVA_
�]'r
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swit El
No. of Emergency Lighting
BatteKy Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALAPJVIS
No. of Zones
—nnd
No. of Detecti5n
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat
IKW
No. of Self -Contained
No. of Waste Disposers
Tpoatamls�
.............
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KVV
ff MuRicipal
Local Connection [I Other
No. of Dryers
Heating Appliances KW
�ecurjrty� �ystems:*
-No. of Devices or Equivalent
No. of Water
Heaters XW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER:
Atrach adaiiionai detall IJ Uvall k�% U1 "a I -J V ...
Estimated Value of Electrical Work: JZO (When required by municipal policy.)
Work to Start: in�p"ections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCIE —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 operatioif 'coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing Pffice.
CBEcK oNE: INSLTR-ANCEE] BONDEI OTBEREI (Specify:)
Icerfify, unde il . s andpenaltieslofpe * ry, that the information on this application is true and complete. r7bJ
r lep - LIC. NO.:
FIRMNAME` (C
Licensee: &L-140 J M Signature LIC. NO.: 6.1
f ap al znl,he Wense number line) Bus. Tel. No.:_b9L_—'_
"c
d P Alt. Tel,
�d s .L JU, Lic. No.
Per rMG 6 1, security work requires Department of Public Safety "S" Lieense:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredbylaw. By my signature below, I hereby waive this requirement. lamthe(C e e) D owner owner�,,S�ent.
Owner/Agent ERMIT FEE:
Signature Telephone No. EP
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
F1 The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass IM
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PAWJAL ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
-C\- The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Mylicant Information Please Print Legibly
Name (Business/organizati6n/Individual):. " Ld e. Lj� Re JA t C
Address:— go
City/State/zip:_ Phone#: hO3 _�62,
A��dan employer? Check the appropriate box:
I am a employer with
4. F1 I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2. El I am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
31. 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152 ) § 1(4), and we have no
't insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. [] New construction
7. E] Remodeling
8. E] Demolition
9. Building addition
10 �Electrical repairs or additions
11. E] Plumbing repairs or additions
12.F] Roof repairs
13TI Other
Amy applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy infonnation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such'
�ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
am an employer that isproviding workers' compensation insitrancefor my employees. Below is thepolicy andjo'b site
tformation.
isurance Company Name:
olicy # or Self -ins. Lic. #: — Expiration Date:
)b Site Address: Citv/State/ZiD:
1tach-ii copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne up td $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
rupto $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Lvestigations of the DIA for insurance coverage verification.
do h erely certify under th e pains an dpen alties ofperjury th at th e information pro vided abo ve is true an d correct.
�gnature: Date:
.lone #:
Official use only. Do not write in'this area,'to he completed hy 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 ajoint 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. Howeve r 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
imsurance. Limited Liability Companies (LLQ 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 retumed to the city or town that the application for the permit or license is being requested, not the Department of
Indusfxial 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 nurnber 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 of 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 bum 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
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
evised 5-26-05 Fax # 617-727-7749
www rnn.o.q anvhii A
=21 0
Location
No. Date 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Y-Wc,b
Other Permit Fee 5-buv— $
TOTAL $
Check # IbO
MR(
15031 Building Inspector
Town of North Andover
fA OMCE OF
COMMUNITY DEVELOPMENT AND SERVICES
27 Charles Street
North Andover, Massachusetts 0 1845
WILLLATM J. SCOTT
Director
(978) 688-9531
C>PPLICATION AND PERMIT
DATE
LOCATION m-2 t 0 M A."
OWNER'S NAME 41 A, f AIV
BUILDER'S NAME
MASON'S NAME
MASON'S ADDRESS
MASON'S TELEPHONE
T -
AoF 1 0 --v
'to j
0
Fax (978) 688-9542
PERMIT #-L,71
MATERIAL OF CHIMNEY CIA- r L i VC5
INTERIOR CHIMNEY -EXTERIOR CHIMNEY -
NUMBER AND SIZE OF FLUES
THICKNESS OF HEARTH— X -I
Will chimney or fireplace conform to requirements of the code and
have rules and regulations been received:
DATE fo , ;L d) —C /or
SIGNATURE OF MASON t� n XTO=
#
EST. CONSTRUCTION COST/CONTRACT PRICE
PERMIT GRANTED 9p, 2- /00, FEE c;2
ROBERT NICETTA, BUILDING INSPECTOR
INSPEC TED
REMARKS
SOLID BRICK REQUIRED
THIS PERMIT MUST BE DISPLAYED ON THE PREMISES
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEAL,rH 688-9540 PLANINTNG 688-9535
WOOD STOVE INSTALLAHON CHECKLIST
Permit
A building permit is required for the installation
of any solid fuel burning appliance. The building permit and
installation inspection are limited to the stove instpilation and not tathestoppri trtn.
S love
A. New
Used.
B. Type/ra6iant V-,
--.Circulating
C. Manufacturer Ve4W)00� LQ�6
—Lab. No. Ar'A 6 &'Wj"a Les + l';j 4
Name/Model No. 0411917�'
Cr)llar size
Dimensions/ Height
__J_.:�ngth —Width
Chimney
A. New
B. Size (flue
C. Other appliances attached to flue (NuMber and
flue size�
D. -Prefab (Manufacturer—name and type)
E. Masonry/Lined
Rue liner (0,
Unlined
lype a MaRuiac(urer)
F. Height (refer to diagrams)
cap
OVER, 10'
I mn
L5 M19
'0
CHIMNEY HEIGHT
Hearth (non -comb Itible)
A. Materials, &I'o<
B. Sub -floor construction
C. Minimum dimensions (refer to diaoram)
Clearances and Wall Protectlon (see stove installation clearances chart)
A. Type of wall protection provided
B. Clearances (refer to diagrams)
FIREPLACE
conNER
MIN. >/"
A
HEARTH
WALUCENTER
780 CMR: STATE BUILDING CODE COMMISSION
Figure 2109-4
CLEARANCES FOR SOLID PUEL BURNING APPLIANCES
ICAP
C 44 -FACTORY-BUILT CHIMNEY
C(Dffnj�p
qz� C
%,j -SUPPORT 11AACKET
NON-COMBUSTIOLE
WALL PROTECTION
A CONN CTOR OVERLAP
3 WOODOURNING
N It STOVE
A
AIR SPA E
12"
YL
12"
NON-COMBUSTIBLE
FLOOR PROTECTION
STOVE INSTALLATION CLEARANCES
';ough Combustible construction.
2 . Thimble required for passage th
3. Plon-cownbustible spxcers required.
4. Clearances on each side of 4 radlAnt Stove with a heat shield shall be measured as If a tlrculatlng type.
Combustible
&'I Asbestos MIllboard
Concrete/Mes on ry
4"Brick Ven eer
Stove Components
Material
Spaced Out 1" 3.
Foundation Wall
spared 01ij- 1 to
Radiant Steve 1.
—Front
360#
Cl,rcul*tlng Stove 1.
—Front
A. Itaidlant Stove 111.
36'0
lips
6.0
—Slde/lock
1
Circulating Stove
tA.
— S I de/Ba--k
6#9
69#
6
5. SIngIg Veff 2.
logo
Connector Pipe
1204
6"
Insulated 211
211
211
211
Connector Pipe I
I
C. Chimney Height Three (1) feet above adjpCent, roof and
(Metal or Masonry) two (2) feet above anX roof ridge within to feet
0. Darver If a damper Is not Included In the Stove construction.
(t must be Installed In the connector pipe.
';ough Combustible construction.
2 . Thimble required for passage th
3. Plon-cownbustible spxcers required.
4. Clearances on each side of 4 radlAnt Stove with a heat shield shall be measured as If a tlrculatlng type.
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