HomeMy WebLinkAboutMiscellaneous - 22 HAMILTON ROAD 4/30/2018Xv
It
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... W.J ... 41p7A ... -491 * -e_
has permission to perform ..... ..................................
wiring in the building of ... ..... J/D. K'Y.4 !� .. . . ........................
at ;,)-._/—A �� f *. �A n ....................................... -North Andover, Mass.
Fee ... 5� .. . ...... Lic. No.
.z� .............
....................
ELEcrR icAL INSP ECTOR
Check # C� 4
92 62
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with tht 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 appl4ation has been accepted by an Inspector of Wires appointed pigsivant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Stich entity shall be responsible for the
notification of completion of the wok 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 Jnspector-of Wires abandoned-and.invalid-ifhe---
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.
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 23 8 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 othervvise applicable expiration date, any permit or approval that was
"in effect or existence4 during the qualifying period beginning on August 15, 2008 and extendingthrough August 15, 2012.
Note: Reapply for new pe.rmit-L�-�
8 — Permit[Date Closed: I/ 2A
0 Permit Extension Act — PermitfDate Closed:
/,
CommoruveJk o/ Ma.aa4u6etta
Apartment o/ Sire service
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 12,32
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 C), 27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: //// O
City or Town of: �Vwe To the Inspector of Wires:
By this application the undersigned gives notice�,f, his or her intention to perform the electrical work described below.
Location (Street & Number) �a�— �4Z16 /—,7B1/ /C// M45s�ic�/��.�ojir�'l N,
Owner or Tenant
Owner's Address
V,
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service /640 Amps /p*G /.NQ Volts
New Service Amps / Volts
Telephone
Yes IZ No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: /e 9w & y /tW
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires �'
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets a
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
o. ot Emergency Lighting
rnd. grnd.
Baqgy Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
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
g
No. of Waste Disposers
Heat Pump
Number
I Tons
........................
"' ""
KW
.."""................
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal El other
Connection
No. of Dryers
Heating Appliances Kms,
Security Systems:*
No. of Devices or Equivalent
No. of Water Kms,
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.
Estimated Value of El ctr' al Work- ��� (When required by municipal policy.)
Work to Start: a Inspections to be requested in accordance with MEC Rule 10, and upon completion.
Q
INSURANCE C GE: 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 OOTV5APis in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify:)
I certify, under the ins and pens ties ofperjury, that the information on this application is true and complete.
FIRM NAME 29 Z,� l LIC. NO.: &Z -75'-6g
Licensee: Signature LIC. NO.: e
(If applicable, enter"exem t" in the license number line.) Bus. Tel. No.:
Address: _ 3�TFF//eXJ;l Alt.Tel.No.
*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 a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ '��
!fF
4�- - s 7,/Z) /��
,A
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
'ompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: '73—
N
4C 6�
City/State/Zip �Q✓fGy "a T //- 600 Phone #
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
e�loyees (full and/or part-time).* have hired the sub -contractors
2. I am a sole proprietor or partner- listed on the attached sheet. I
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
fSCI
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
121-1 Roof repairs
131-1 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 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 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.
Insurance Company Name:
'Policy # or Self -ins. Lic. #:
Expiration Date:
blob 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 ci under th pains and enalties of perjury that the information provided above i true nd correct.
Signature: l0
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 #:
Location P-2 04"' / 4"' P:;(
No. 301-0 Date z"2 7,S
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 1_�r-2-2
16174 (6 -1 -
Building Inspector
r7
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
for Offidd Use
BUILDING PERMIT NUMBER: 3 q p P
ATE ISSUED: a _� �_ O 3
SIGNATURE: cs--�-
Building Commissioner/I r of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
2-2-
1.2 Assessors Map and Parcel Number:
016 001179
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
(D, )Oo loo "
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Regaired Provided
1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information:
Public it Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal r3— On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
O v,r r' C..1L t L12o
Name (Print�)l�n Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction`Aupervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
M
M
3
Z
O
e
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 Description of Proposed Work check all licable
New Construction ❑ I Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑
Accessory Bldg. ❑ I Demolition ❑ 1 Other ❑ Specify
Brief Description of Proposed Work:
A
bA b> rival is
. L _ 1 _ 11
I SECTION 6 - RSTIMATFD CONSTRUCTION Cnv%TS I
Item
Estimated Cost (Dollar) to be
Com eted by permit ap2licant
QFI+'ICIAL USE ONLY;-. V
1. Building
741.7,7a
(a) Building Permit Fee
Multiplier
2 Electrical
`j
(b) Estimated Total Cost of
Construction
®Arm
d�JJ
3 Plumbing
Building Permit fee (a) x (@)
Off.
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number
S
Jr.t 11V1N 1a UWINtK AU 1t1UK1LA11U1N TU HE CUMYLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, l ggo-,,'�L ?r -')44A 190--fo"— as Owner/A+t4h*ize&Agent of subject property
Hereby authorize to act on
My behalf, 1/rall matters relativ o work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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
of
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS I ST 2 ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DMIENSIONS OF GIRDERS
Iff IGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL, OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
e
1
1
Town of North Andover
Building Department
27 Charles Street .gSSaCHU5ES4
North Andover MA 01845
Tel: 978-688-9545
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE Z-- '-14 0� I
JOB LOCATION Z �^ �wyt,� l6A fZ
Number 1 Street Address Section of Town
"HOMEOWNER C g 5 74.16 769 O l q
Number Home Phone {� Work Phone
PRESENT MAILING ADDRESS 2-a 46-v\EZA
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of six 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 109.1.1)
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 to six family dwelling, attached or detached structures ac-
cessory to such use and and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official,
a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
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 requiremepq.
HOMEOWNER'S SIGNATUR
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0 Construction Control.
.
3
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. R- > t-
�G�� ce*+aZ4,, ✓ • (q'111)656 2666
(Location of Facility)
Signature of Permit Applicant
- 07 x-03
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
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Date. �/- 2 1/- 6 -->
...........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that J.11.11-*?�;�'. 5 ... 05� n .................
has permission to perform .... P ...............
plumbing in the buildings of ... D.(, ...................
at. ............. North Andover, Mass.
Fee . ...... Lic. No./..,. .. .......
RLUMBING INSPECTOR
Check #
5594
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS /
_ - Date
Building Location 22 I Lr -01V ed. Owners Name Dk—e-19W1 & -'JDU VL3f Permit
y� 0 _ Amount
Al- H-n/lvto/94S Type of Occupancy S' j/V Cid
A
New ❑ Renovation a Replacement ® Plans Submitted Yes [:] No
FIXY#RES
WMMMMMMMMMMMMM
mmmmm�mn
Off
IM ..•
.............,i.....
MMMMM
„•
�■���������■�����������
mom
(Print' or type)
Installing Company Name
Address 1,212- S A I F N ST.
-4cg-3- .z0
Name of Licensed Plumber: .. — lJ% - z
Insurance Coverage: Indicate the Wof insurance coverag checking the
Liability insurance policy 11 Other type of indemnity ❑
Check one:
11 Corp.
UPartner. .
11 Firm/Co.
box:
Bond
Certificate
Insurance Waiver: the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
, a
ignature Owner14
Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Cod d Chapter 142 of the Generaj Laws.
By: igna e of Licensectum er
Title
Type of Plumbing License
/
City/ License Number Master ® Journeyman
APPROVED (OFFICE USE ONLY u
The Commonwealth of Massachusetts
Depertrrwt of Public Salary
Tr BOARD OF FIRE PREVENTION REGULATIONS 527 CMA 12:00
APPLICATION
77-7
F
ffs Use only (�
aff z �� r
Flo
ew alar" �U
FOR PERMIT TO PERFORM ELECTRICAL WORK'
M war m ee aw"a"" to Neem Cue w+a or trd„a„, Cea.� !tr taui ttov K
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION
Oate
Cirf or Town of
The undersigned applies for a permit to Perform late electr" work described tieiow.
Location (Street a Numt»r._i--fib ,
Owner or Tenant
Owners Address_ CQiV►/� t
Is this pemnit in Conjunction *1h a building permit c
� res ❑ ra
Purpose of $uildin P---�.. l/
Utility
Existing Service Amps r Volts
Nei" Service—_._J►mps___.__ , r
Number of Feeders and Ampacity
Location and Nara of Proposed
To the tnsNNtCtar of W,ras:
(Ch -;k Appropriate Box)
Authorization No.
Overhead ❑ Una" ❑ No. of Metem—
Overhead Q Undgrd ❑ No. of ldebrs
FIRE ALARMS No. al
No. of Detection and
Initiating 0eviCss
No. of Sounding Devices
No. of Sell Contained
001ecticn►Sounding Devices
INSURANCE COVERAGE: Pursuant to the irentents of Massachttsetta G*nWW Laws
I have a current Liability Insurance PoNry Ir��,�3 Completed Op*ratbns
VOO proot of am* to this office. YES ��''i�yp0 Q Coverage or its substantial equiv�en[. YES��.N[ f hoar• submitted
N You nave Checked YES. indicate Ute type of eoverege by checking the appropriate box.
INSURANCE 8ON0 ❑ OTHER ❑ (Pisa$* Sptlafy)
Esdn ood Vel* of Electrical Worts S— LL` )
Walt to Start`7' 11
Signed under the penaltm of Deriurv-
FIRM
Licensee
Inspection oat* Requested:
(Expiration
Rough Foal
NO. --01 2 6
LIC. NO.,
No.,3-7 a -9-i 1.7
O wash S INSURANCE WAIVER: anlam aware that the Ucensea does not hm � �ur�ee Coverage or its Sub[startllat �
nKasaacnusetts General Caws. aria treat my signature on this appocarton wairas this regtorennent. Owner Agent equivalent 3reguired by
(Signature of Owner or Ammet Tel*pnong NO
Date ... ..... ...
2595
V,ORT"
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that ......... ....... /,-- ........
has permission to perform ..... ........ ..... V -d -e.(.10
j..LA .....................................
wiring in the building of...
at .... ........ Q . .................. I North Andover, Mass.
Fee.k.j-.()()... Lic. No. V.1W.Vi4 .............................................................
ELECTRICAL INSPECTOR
0419#14*5' IK IS- 00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
I�
in Ap
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO. DO PLUMBING
(Print or Type)
Mass. Date ii"' /� 19 21— Permit# �- 6 ! q '• `�
Building Location A9 �Mt%1bAj Kcl, Owner's Name WinesIftilkic-i/) A677A,;
New ❑ Renovation ❑ Replacement f D
FEATURES
Type of Occupancy
Plans Submitted Yes ❑ No ❑
Installing Company Name A a Check one:
Address L4 f' O'Corporation
❑ Partnership
Certificate
Business Telephone__sb
❑ Firm/Co. _
Name of Licensed Plumber_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes e No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy t7 Other type of indemnity ❑ Bond ❑
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Anent Owner ❑ Agent ❑
I hereby certify that all of.the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Plumbing Code and Chanter 142 'of the Gpnaral I -
By
i -
Title
City/Town
nPPRown nFFI('F I ICF nNI Yl
Type of 1. ense: Master W?� Journeyman ❑
License. Number_ g (-, Q 9
..-
■■■■■■■■■■■■■■■■■■■■■■■■■■■i
2ND FLOOR
■■■■■■■■■■■■■■■■■■■■■■■■■■■■
.... -
■■■■■■■■■■■■■■■■■■■■■■■■■■■�
..-
■■■■■■■■■■MEMO
■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■I■
Installing Company Name A a Check one:
Address L4 f' O'Corporation
❑ Partnership
Certificate
Business Telephone__sb
❑ Firm/Co. _
Name of Licensed Plumber_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes e No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy t7 Other type of indemnity ❑ Bond ❑
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Anent Owner ❑ Agent ❑
I hereby certify that all of.the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Plumbing Code and Chanter 142 'of the Gpnaral I -
By
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Title
City/Town
nPPRown nFFI('F I ICF nNI Yl
Type of 1. ense: Master W?� Journeyman ❑
License. Number_ g (-, Q 9
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Date.... : ........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .......................................
has permission to perform ....................................
plumbing in the buildings of ...............................
at ...................................... North Andover, Mass.
Fee......... Lic. No .......... ........... .........
PLUMBING INSPECTOR
09/25/53 11:50 10 -CO PRA
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
Date..? ...P). S ...... .-3.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies'that ..... % .Y r + c k v ti '"
..........................................................................
has permission to perform ......2.. E' I W. ` .-
...
.......................`.................................
wiring in the building of ......... ? r r
at ....o.�.... �� A V� `.'. ° ^'......!� C,O..................... .North Andover, Mass.
........ .....
Fee ... Lic. No. /v..... . J • �e C u i A
....... 1!!!.. .........................
ELECTRICAL INSPECTOR
Check # � -� doo
4354'
THEC0AW0NWE4L7H0FAA,S,4CR%,S`E+77S Office Use on .
DEPARTNMVTOFPUBLICSAFETY Permit No. ��
BOAROOFFIREPREVE MONREGUL4HON9527C�ZI2 00
Permit
Occupancy & Fees Checked
APPLICATIONFOR 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) Date
['own of North Andover To the Inspector of Wires:
.he undersigned applies for a permit to perform the electrical work described below.
,ocation (Street & Number) 2,2 ICTJ>� �y¢-:
)wner or Tenant
)wner's Address '7 Z U�z (�-t3Y�
this permit in conjunction with a building permit: Yes [I�No r7 (Check Appropriate Box)
urpose of Building r�pMa�
I��1^
.�— �rC}j-A t/'pp,,N Utility Authorization No.
xisting Service �� Amps
/ Volts
Overhead UndergroundNo. of Meters
ew Service Amps
/ Volts
Overhead M Underground No. of Meters
umber of Feeders and Ampacity
)cation and Nature of Proposed Electrical Work
5 -}- _
To. of Lighting Outlets
No. of Hot Tubs
M/A No. of Transformers Total
KVA
fo. of Lighting Fixtures
17
Swimming Pool Above
Below Generators KVA
ground
El
ground
'o. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting BatteryUnits
o. of Switch Outlets
No. of Gas Burners'
o. of Ranges ^
No. of Air Cond.
Total FIRE ALARMS No. of Zones
i
Tons
�. of Disposals
No. of Heat
Total Total No. of Detection and
Pumps
Tons KW Initiating Devices
). of Dishwashers
Space Area Heating
KW No. of Sounding Devices 3
No. of Self Contained
Detection/Sounding Devices
i. of Dryers ^
L
Heating Devices
KW Local Municipal Other
Connections
of Water Heaters KW
No. of
No. of
Signs
Bailasis
Hydro Massage Tubs
No. of Motors
Total HP
IER-
M XCowrdge Rustmltodie m uitmierdsofMassadn>seftsGmrdIams
aautentLallityhUMMPOkY C'MTie1E Covera�eorASAbsUtlalequivalmt YES NO
ssabrnaidproofofsame�theOllioe YES
mgthe If}oul�edledtedYES, pleweir type
theofooveIrageby
-_--ppaybox 11��..11
Q MIER
roSt%t �_bspectionEW-RoWested
iumtrtTieptmi imofpaoT..
EVirdmD
ESmrrkd Vakxofl1chiral Wotk $
Rough
r
.NAI`M LicroseNo.
ee Signature
;c Alt Tel No.
ER'SINSURANCEWAIvER Iamaware that dr.Licmq2�does nothavethemstuanoemvaageoritsmbstantolequivalaltasoptedbyNla%achigctGmalLam
itmysignahueonthispmr-itapplicationwaives thisregttirement
se check one) Owner Agent
Telephone No. PERMIT FEE $
Signature ot 77-ner or Agent
Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name: li ��it�'i Cy ✓`,Vj at/�
a
I nratinn- r��- L. UA 1Aw i' F-�51.� 1 /�. 1 \ 1 _ 1A e . N 01% i /J
I am a homeowner performing all work myself.
vv 1 I am a sole proprietor and have no one working in any capacity
85 7* 16
I am an employer providing workers' compensation for my employees working on this job.
Company name.
Address
City: Phone #
Insurance. Co. Policv #
Company name:
Address
City: Phone #7.
Insurance Co. Policv #
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 $1,500.00
andfor one years' imprisonment-as-well_as-ch4l penalties in-theiarm-da ST_OP.VYORK ORDEP—aW_a.fine_of-($IjW-OD)-a day.agabst.me_ 1
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/ do hereby certffy under the pains and penalties of perjury that the information provided above is true and correct.
Signature Bate
Print name Phone.#
Official use only do not write in this area to be completed by city or town officiar
City or Town Permit/l icensi
El Check if immediate response is required Building Dept
El Licensing Board
E] Selectman's Office
Contact person: Phone #: E] Health Department
F, Other