HomeMy WebLinkAboutMiscellaneous - 224 HAY MEADOW ROAD 4/30/2018 242 HAY MEADOW ROAD �\
210/104.B-0078-0000.0 /moo 40
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4
Date. ...��°.......p.�.
S
NORTI{
°f�"`°:•'"a TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
�,SSACNUS�
This certifies that . ............. .. ................. .. ! .....4.:.. .. ..................
has permission to perform �. .......`.�......d......................................
wiring in the building of.A4qa*� ...... ................................
,North Andover,Mass.
04 Fee..................... Lic.No � ............
ELECTRICAL INSPECTOR
ot-
Check # `
8728
,r
N\ Commonwealth of Massachusetts official use only
Department of Fire Services Permit No. ''�'7 -2?
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] Qeave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINTININKOR TYPE AU NFORA"TION) Date: p
City or Town of: NORTH ANDOVERTo the p� l
By this application the undersigned gives notice of his or her intention to perform the Inspector
tr.cal wwork idescribed below.
Location(Street&Number) 2-24
Owner or Tenant Mh 2iL Z--�k M,s t=
Owner's Address vK l Telephone No.
Is this permit in conjunction with a building permit? Yes No
Purpose of Building t=om t t> TC L r.,c— ❑ (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No.of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No,of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
t �l TCrlf�►a 1�,►—�1�i�'Z,
- Co- letion of the followin table Pngy be waived by the Inspector of Wires.
{ No.of Recessed Luminaires `7 No.of Ceil.-Susp. (paddle)Fans No.of Total
Transformers "7A
No,of Luminaire Outlets No.of Hot Tubs Generators I';VA
No.of Luminaires Swimming Pool Above In- o.o mergency M
d. d. ❑ Batte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches '2- No.of Gas Burners No.of Detection and
No.of Ranges ( No.of Air Cond. Total initiating Devices
Tons No.of Alerting Devices
No.of Waste Disposers .Heat Pump Number Tons KW _ No.of Self-Contained
Totals: "'"" - Deteetion/Alerita Devices
No.of Dishwashers Space/Area Heating KWLoca ❑l Municipal
Connection El Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of WaterNo.of No.of Devices or Equivalent
, Sis BBall
Heaters al of Data Wiring:
Ballasts . No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total gp Telecommunication Wiring:
OVER:
No.of Devices o E uivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value f��r
k: 3 570 f7 .
(When required by municipal policy.)
Work to Start Inspections to be requested in accordance with MEC Rule 10 and upon
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical wok 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 (3 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
Licensee:` JAS 1 Si LIC.NO.: i 3 14.3
(f I a 1: p gnature LIC.NO.: � 23 3
pp 'cable, enter exempt"in the license number line.)
Address: 100 TeL No.:-l8 WIIA't, .03 2-z
*Per M.G.L c. 147,s. 57-61,securi work requires D „ „ Tel.No.:Z�l•WS t i P,Z D
q epartment 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(c
Owner/Agent heck one) ❑owner El owner's agent
Signature Telephone No. PERMIT FEE. $ 0
,�
W
��'�
w
� ` .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia .
Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plnmbers
Applicant Information Please Print Ledbly
Name(Business/Organiration/individual): �A S \
Address: k 0(2D �A/S.,1 1,7 SZ,
City/State/Zip: WAKEF'te?b,MA o V3,50 Phone #: . � ` 2 4 S ,L8 Z �
Are you an employer?Check.the appropriate box:
1.El I am a employer with Type of Projeo(required):
a general contractor and I 6. Q
New construction
employees(full and/or part-time).* have hired the sub-contractors
2. :,I am a.sole proprietor or partner- listed on the attached sheet.t7. Q Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for mei' any capacity, workers' comp.insurance.
[No workers'comp, insurance 5. 9, ❑Building addition
r p ❑ We are a corporation and its
required.] officers have exercised their 10•❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself [No-workers'comp, c. 1.52, §1(4),and we have no 12.required.] ❑Roof repairs
insurance re
Q ] ,employees. [No workers' 13.Q.Othar
camp. insurance required_]
'Any applicant that checks bo)'#I 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.
am an enspinyer that is provieing:workers'compensadon insurance for nry.employees: Below is the policy andjob site
information.
Insurance Company Name:
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
Iq Investigations of the DIA for insurance coverage verification.
t
t do hereby cerci under the p enalties of perjury that the information provided above is true and correct
Si Lure: Date:
Phone#: LA ZI-S LES ri d
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#:
Information and Instructions y
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,assvoia6on,corporation or other legal entity,or any two or mom
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 ti
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 1
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,notthe 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 irsurance-Iicense 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 tare 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 w
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 irk
1
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 1-8.77-MASSAFE
Fax#617-727-7744
Revised 5-26-05www.mass.gov/dia
Date. �J. .'. 7- e'
01 A
TM TOWN OF NORTH ANDOVER
,..°M
p PERMIT FOR PLUMBING
,SSACMUS
This certifies that . .-: . .r-.^. . . . . . . . . . . .'�:�"�"�f.�.�'.y. . .'. . . . . .
has permission to perform . '-
!. .. . . . . . . . . ... . . . . . . .
plumbing in the
/buildings of .-...,.. . . . . ., . . . . . . . . . . . . . . . . . .
North Andover, Mass.
7/7
Feed/. . . . . . .Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
Check # g
8056
o
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS q
g r�P� Date �'� O/
Building/Location wners Name SQ/� SE' Permit# o 5 ro
I o / T t lV V/ �G2 Amount tj/.
Type of Occupant
New Renovation Replacement 0----Plans Submitted Yes No
FIXTURES
H ZO F
W
W W H W F ° Z z H
x a °
U W o w w a Z A A a
H x � x x ° x w x W w x
a0
0-4
KRBM
RASEVENr
]Sl:ROOIt
M 110CIR
2M Hsi
4IH FLOC R
SIl<I FIS
6M HOOK �
7M FLOOR
8MHom
(Print or type) Check one: Certificate
Installing Company Name h-e /'/2 l� C M/1j/7Q.�S 4 " ❑ Corp.
Address /" v Partner.
O
usmess Telep one p42
Firm/Co.
Name of Licensed Plumber: Z /t co/K/h
Insurance Coverage: Indicate the type of insurance coverage by checking the appr ate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
signature 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St to Plumbi*g Cod Chapter 142 of th�6GetrEral Laws.
By: Signature or Eicenseariumuc,
Title Type of Plumbing License
City/Townmr Master l
aster Journeyman ❑
; 2
APPROVED(OFFICE USE ONLY
I
The Commonwealth of Massachusetts
kj ! Department of Industrial Accidents
VIM
Office of Investigations
600 if
rashirc;ton Street
Boston, MA 02111
www-massgov/dia .
Workers' Compensation Insurance Affidavit-. Builders/ContractorsMiectrician/Plumbers
Annlicant Information
Please Print Lembly
Name (Business/Orgeniza6on/individual):_
Address:
City/State/Zip:f'���j0/�19 A) co /
Phone#: . 0 O'
Are you an employer?Check the appropriate box:
1.Q 1 am a employer with 4, Tof project(required):
❑ I am a general contractor and I
�-, em�tove-es(full and/or part-time).* have hired the sub-contractors
contractors 6.7[]New construction
2.s�am.a:sole proprietor or partner- listed on the attached sheet I 7 ❑RMM1 ?mg
ship and have no employees These sub-contractors have s. []Demolition
working for me.in any capacity, workers' comp.insurance.
[No workers'cola insurance 5. 9, Q Building addition
p ❑ We are a corporation and its
required.) officers have exercised their I0.Q Electrical repairs or additions
3.Q I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself,[No•workers'comp, c, 152, §1(4),and we have no
insurance ired t I2.7 Roof repairs
�N ]. employees. [No workers'
comp. insurance required.] l3.Q.Other
*Any applicant that checks bi #I must also flit out the section below showing their workers'aompensafion policy information
t homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Corrtnictors that check this box must i�nacffed an additiaaal sheet showing the name of the sub-contractors and their workers'c=m in�mration.
r ref i
am an employer that is providlMg:workers,compensation insurance or a to em Below is the o ' and'ob arta
information f �' P Y p &7
Insurance Company Name: '
Policy#or Self-ins.Lic.#:
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$4500.00 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 certify under the pains and penalties of perjury tbatjgte in
forMwtion provided above is true and rorreeL
Si tore:
Phone#: d �—
EBoa
only. Do not write in this area,to he completed by city or town okra!
n: Permit/License#
ority(circle one):
I. Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
son: Phone#:
y y"
Information a nd 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 a joint enterprise,and includirig 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 Ccensing 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 Icoverage 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),addresses)and phone number(s)along with their certificates)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
empioyees,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 retuned to the city or town that the.application for the permit or license is being requested,notthe 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 numberlisted below, Self insured co*npanier shoeld entwtheir
self insurance license number on the'appmpriate 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 permitJlicease number which wiII be used as a reference number. In addition,an applicant
that must submit multiple perinit/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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigkations 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 #617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
° 16 U Date..................................
,°OR7M
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SsACHUSEt
This certifies that
l„.02........
has permission to perform..... ....... :J - ..... ..<.....................................
wiring in��the building of..... ..�.,......................... . ...........................................
d 7 �-' ,Alorth Andover,Mass.
Fe�1.4............ Lic.Nol. /V .. ..Y�....
ELECTRICAL INSPECTOR
1 V//
04/20/99 14:30 35.04 PAID
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
Office Use Only
c7f he C90mmonwealt of Permit
Permit No. ��o.
Deportmtnt of Public $aftta Occupancy A Fee Checke6_V
BOARD OF FiRE PREVENTION REGULATIONS 527 CMR 3/90 peeve blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date APRTL 5. 1999
City or Town of NORTR ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 224 HAY MEADowN ROAD
Owner or Tenant MARC SAMSE
Owner's Address (978)685-9960
Is this permit In conjunction with at building permit: Yes ❑ No 19 (Check Appropriate Boz)
Purpose of Building Utility Authorization No.
Existing Service Amps_J Voits Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps_J Volts Overhead ❑ Undgmd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets No.of"0117161118 No.of Tmnsformer Total
KVA
No.of Lighting Fixtures Swimming Pool Above In-
gmd. ❑ gmd. ❑ Generators • KVA
No.of Emergency Lighting
No. of Receptacle Outlets No. of ON Burner Battery Units
No.of Switch Outlets No.of Gas Burners FIRE ALARMS No.of Zones
No.of Ranges No.of Air Cond. Tbtal No.of Detection and
tons Initiating Devices
No.of Disposals No-of Heat Total Total
�v Pumps Tons KW No.of Sounding Devices
f Self Contained
No. of Dishwashers Spacs/Area Heating KW Deteetkm/Sounding Devices
? No.of Dryers Heating Devices KW LocalMunicipal Other
❑ Connection ❑
No.of No.of Low Voltage
No.of Water Heater KW Signs Ballasts Wiring BURGLAR ALARM & DEVICES
No. Hydro Massage Tubs No.of Motor Total HP
OTHER: ONE SMOKE DETECTOR
INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or Its substantial equivalent. YES G NO O 1
have submitted valid proof of same to the Office.YES O NO ❑ if you have checked YES,please indicate the type of coverage by
checking the appropriate box.
INSURANCE O BOND. O OTHER O (Please Spedfy)
Estimated Value of Electrical Work i
1+74.00 (Expiration Date)
Work to Start 4/7/99 Inspection Date Requested: Rough Final 4/10/99
Signed under the Penalties of perfury: ,•
FIRM NAME LIC. NO. 12310
Licensee nnna 1 d A- Arnnka nature LIC. NO. . 12310_
Address 111 Morse Street._Norwood. MA Bus.Teel.No. (203) 78 —4008
All.Tel.No. l781l 97fi_t 111
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the Insurance coverage or lis substantlal equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent
(Please chock one)
(Signature of Ownor or Agont) Telephone No._. PERMIT FEE S. 35.00
f
TOWN OF
SYSTEM PUMPING RECORD ;
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION `
(example:left front of house)
DATE OF PUMPING: QUANTITY PUMPED : , O� GALLONS
CESSPOOL: NO YES EPTIC TANK: NO YES
I
NATURE OF SERVICE: ROUTINE EMERGENCY
i
I
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
i
COMMENTS:
CONTENTS TRANSFERRED TO:
�' `v
1
3 9; Date.............. ..... ..........
f ND,r"9
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SSACMUS� /
This certifies that ............:0.....,t�............'..... �.`., .�......................
has permission to perform ...:............ ...... ........�.........r ......................
.. C
wiring in the building of......... !!
�?.�+ ......e..............................................
building
2�t....... .. ..7.....J..!...C�. ?.P d epi �(� t/ orth Andover;Mass
Fee...., ............. Lic.No.�1.f!c,..j71.....�........7!.................................
,".ELECTRICAL INSPECTOR
Check # �ff7
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
r i
Coni,nenwea��er///alMe�r�eel� Oficial Use Only
c� e� (� Permit No.
�1Jeparftne,tl o`_%V Je,yvicel Occupancy and and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/99]_ leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to he performed in accordance with the Massachusetts Eltcirical Code(h1EC),527 CAIR 12.00
(PLEASE PRINT M INK OR TYPE:ILL hVFOWAT1019 Date: �j -��j-p
��City or Town of: o V a To the Inspector of Wires:
By this application rile undersigned gives notice of lets or her intention to perform the electrical work described below.
Location(Street R N liber) e �—� _2 e� 'Y u- 'nuo IM ,
Owner or Tenant YYl Telephone No.
Owner's Address
Is this permit in conjunction with a uilding cr III? Yes No
y „p ❑ � (Check Appropriate Box)
Purpose of Building �e� , / �u�Y>1 Utility Authorization No.
Existing Service Amps / Fells Ovenccad ❑ Undgrd ❑ No.of Meters .
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters.
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: _ r�
c '
Completion ofthe olluinlnQ table nitry be nclved by the hi ctor of IVires.
No.of Recessed Fixtures No.of ccil.4usp.(Paddle Fats I °•of ota
Transformers KVA
No.of Lighting Outlets No.of Plot Tabs Generators KVA
No.of Lighting Fixtures Swimming Pool ove ❑ n- ❑ o.o mergencyLighting .
rnd. rnd. Batte • Units
No.of Receptacle Outlets No.of On Boaters FIRE ALARIM No.of Zones
No.of Switches No.of Gas Burners i o•o Detection an Total t
Infilatiniz Devices
No.of Ranges No.of Air Coed. 1 Tons No.of Alerting Devices
r cat pump um er pns _ _,_ i o.o e - onta ne
No.of Waste Disposers Totals: Detection/Alertin Devices
No.of Dishivashers Space/Area Heating KW Local ❑ unictpa ❑ Other
Connection
No.of Dryers Heating Appliances KW ecurity Systems:
No.of Devices or Equivalent
To—.o a t e r o.o i o.o
Heaters h�V Ballasts Data Wiring:
SiA is No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Alotors Total HF 1 a ecommumcations 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 nary issue unless
the licensee provides proof of liability insurance includii'tS"completed operation"coverage or its substantial equivalent. llie
undersigned certifies that such cove a is in force,and las exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) In)_,�))— On
(Expiration Date)
Estimated Value of Electrical Work: - (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with IVtEC Rule 10,and upon completion.
I certify, itinter the a►its and penaltieso perjury,them die information on this application is trite and complete.
M
FIRNARIE: S (_ 1-6 1,4GO ' LIC.NO.: A/37/ 7-
Licensee: �`jT7C--C&A_) Signature L1 C.NO.: q�
(If applicable, enter "tr.r t-in c I iccnse r ne. Bus.Tel.No.:
Address: • ♦. � Alt.Tel.No.: 36
OWNER'S INSURANCE WAIVER: I am aware that the Lice toes not have t e liabilityinsurance coverage normally
x e ow ,
R
required b law. fav nt si+nature below,1 hereby waift this re uiremenl. I am the check one owner owner's agent.
rM Y Y b Y 9 ( )❑ ❑
Owner/Agent
Signature Telephone No. FPERMIT FEL•