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North Andover Board of Assessors Public Access
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Sroperty Record Card
Location: 24 PETERSON ROAD
Owner Name: KANTESARIA, SUKESH, H.
KANTESARIA, SWAROOPA
Owner Address: 24 PETERSON ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 0.12 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 1556 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 319,100 319,100
Building Value: 170,400 170,400
Land Value: 148,700 148,700
Market Land Value: 148,700
Chanter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1888960&town=NandoverPubAcc 5/17/2012
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Date -77.) 115 ...............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
,� sSACHUtiB
.This cernfies that .....�....'. Q1f
..........I....
..........
has permission for gas install tion ............... .N. e„...............................
> in the;buildin` s of ........k—A- ....... . ........ ................................................
:::.. . . ..c
.................................................................. North Andover, Mass.
Fee ::.:.....
.....................................................................
p GASINSPECTOR
Check #,5q
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY o r' MA DATE 12 Q I PERMIT #
JOBSITE ADDRESS Z ` e�l-c Esc ► U A�� OWNER'S NAME
GOWNER ADDRESS TE ��FAX
TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALO
T
PRINT
CLEARLY NEW: RENOVATION: 0 REPLACEMENTr4Rfr PLANS SUBMITTED: YES N0 0
APPLIANCES Z FLOORS- BSM'l 1 1 2 1 3 1 4 1 5 1 6 7 8 9 1 10 11 12 13 14
BOILER 11 111 111 111 111 111 111 1111
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUPAIR UNIT
OVEN
POOL HEATER
ROOM/ SPACE HEATEF
ROOF TOP UNIT
WNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE CSE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY 0 BOND
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.
CH CK ONE ONLY:
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this applicatio re true and aca
and that all plumbing work and Installations performed under the permit issued for this application will be In q3 pliance with
Massachusetts State Plumbing Code and Chapter 142 of the C,eneral Laws.
PLUMBER-GASFITTER NA ! ICENSE # 6?� I
MP MGF ® JP ® JGF Q L GI ® CORPORATION # PARTNERSHIP#�
COMPANY NA i it ADDRESS ' (✓G_
CIS' ✓ _ STATE ZIP TEL
FAX I� CEL�AIL P p c
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741
•. The Commonwealth;of.Massachicsetts, ,-
Department oflndustrialAccidents
` 1 Congress Sheet, °Suite 100 '
_ Boston, MA' 02114 2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name
Wi m a
City/State/Zip: �L' .r Phone #: 9 �A--- 6fl —d -?2 (0
5. ❑ lain a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employ.,ees. [No workers'. comp. insurance required.]
*Anv annlicant that checks box 41must also fill out the section below showine their workers' comnensatiot
I Homeowners who'submit this affidavit indicating they
$Contractors that check thtsbpx must attached an additic
employees. If the sub-contradiors have employees, they
f'am an enipioyer thai is providing workers'
information.
Insurance Company Name:
. AAr
Policy # or Self -ins. Lic. #;
Type of project (required):
7. ❑ New construction
8. 0 Remodeling
9. ❑ Demolition
10 ❑ Building addition
I ❑ Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13.❑ Roof repairs
14. ❑ 'Other
L policyinformation.
are doing all work and then hire outside contractors must submit a new affidavit indicating such
mal sheet showing the name of the sub -contractors and state whether or not those entities have
must provide their workers' tomo. poliev number.
insurance for my employees.' Below is the policy and job site
Expiration Date:
Job Site Address: City/State/Zip:.
Attach a copy of t_e orkers' compensation policy declaration age:(showing the policy number andexpiration date).
Failure to secure coverage a equired under c..152, §25 a riminal violation punishable by a foie, up to $1;500.00
and/or ode -year imprisonment; well as ci altt sin. Form fu STOP WORK ORDER and a fine of up to $250:00 a
dayainst the violator. A copy f this sta nt mayib rward to the' Qffice of Investigations of the, DIA for insurance
coverage verification.
I do�hereby certify under
the information provided above is true and correct.
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 #•
M
t`
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 a joint enterprise, and including the 'legal representatives of a deceased employer, or the
receiver o'r "tr6s'te�,e of,an individual; partnership, association -or other legal entity, employing employee's. 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.' -
I
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 liasnotproduced acceptable evidence of compliance with the insurance`toverage'required.
Additionally, MGL chapter 152,'§25C(7) states "Neither the commonwealth nor anyof 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 Departmerit,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 . town that the application for the permit or license is being. requested, riot 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 onthe 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 (ifnecessary) 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
Location,`�C toy
lD
No. Date
-TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $ /
Water Connection Fee $ /677, Sy
TOTAL
� B idin hs r
29/ `
07/29w%9!s�� I 7/9�9$;V `
.� PAID
i -:?
902 Div. P IidWorks
` Location
No. S d Date /"ZY
40*T"
TOWN OF NORTH ANDOVER
p: ••lAhLOw
Sc�
„
Certificate of Occupancy
$
`
Building/Frame Permit Fee
$
s�cMus
Foundation Permit Fee
$ A0 0
t,
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$ %
�
isa. oo
I
f�ng Inspector
N2 10,0 9'�
M/1% 08:5
Div. Public Works
MJ.� � ���
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173
Locations
No n Date 2-2"
ORTH
N�ao
TOWN OF NORTH ANDOVER
pf ,
,�aa OL
p
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
Sewer Connection Fee
Water Connection Fee
TOTAL
'J
%� 1�116f�5 12.16
Building Inspector
705.00 PAIR
Div. Public Works
PERMIT NO,
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
.MAP 4-40.
ONE' _�
LOT NO.
SUB DIV. LOT NO.
2 RECORD OF OWNERSHIP (DATE
-I
BOOK 'PAGE
1
LOCATION
PURPOSE OF BUILDING
l
OWNER'S NAME
NO. OF STORIES 0 SIZE
OWNERS ADD' TSS
BASEMENT OR SLAB 1
71
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST -//k 2N
l �d
3RD
BUILDER'S NOME
SPAN 19 s
DISTANCE TO NEAREST BUILDING
(/
DIMENSIONS OF SILLS
_ --
---
DISTANCE FROM STREET _ +/-
" POSTS 9 X4
DISTANCE FROM LOT LINES - SIDES/r TIC,.REAR
/�
!
GIRDERS
j
AREA OF LOT .t,„
FRONTAGE
HEIGHT OF FOUNDATION '��'' �
/ "
THICKNESS 6� 1
IS BUILDING NEW
SIZE OF FOOTING l�
I
X
IS BUILDING ADDITION A./D -
MATER:AL OF CHIMNEY
'
IS BUILDING ALTERATION Nn
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE r „
Y
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
.
IS BUILDING CONNECTED TO NATURAL GAS IINE
-
INSTRUCTIONS
F 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 REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
E E
PERMIT° GRANTED
7—ze! ,9
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M ' I
9E PERMIT
3 - � PROPERTY INFORMATION
LAND COST
EST. BLDG. COST 00 U )
EST. BLDG., COST PER 94. rldX 4/C-
EST. BLDG. COST PER ROOM 1
SEPTIC PERMIT NO.:
4 APPROVED BY
BUILDING INtP[C' ilt
OWNER TEL. #
CONTR. TEL. # 'V -r jV-
CONTR. LIC.#
H.I.C. #
19.
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M ' I
9E PERMIT
3 - � PROPERTY INFORMATION
LAND COST
EST. BLDG. COST 00 U )
EST. BLDG., COST PER 94. rldX 4/C-
EST. BLDG. COST PER ROOM 1
SEPTIC PERMIT NO.:
4 APPROVED BY
BUILDING INtP[C' ilt
OWNER TEL. #
CONTR. TEL. # 'V -r jV-
CONTR. LIC.#
H.I.C. #
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY = _4. 5toR1E5 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY '- OFFICES LOT LINES AND EXACT DIMENSIONS OF .BUILDINGS. WITH PORCHES. GA -
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION _ 8 INTERIOR FINISH
CONCRETE" _
CONCRETE BL: K. PINE
BRICK OR STONE P
PIERS PLASTER
-
_ DRY WALL
UNFIN.
3 BASEMENT. �. • I _ - - "
AREA FULL 1 II FIN. B'M'T' AREA I
'T
4 WALLS 9 FLOORS
CLAPBOARDS - - B 1
6Rl4P CONCRETE _
WOOD SHINGLES EARTH -" _
ASPHALT SIDING _ _ HARDIIJ'D
ASBESTOS SIDING COMMON
VERT. SIDING ASPH. TILE _
• STUCCO ON MASONRY _
-STUCCO ON FRAME, _
STONE ON MASONRY
WIRING
_
STONE ON FRAME
SUPERIOR I'� POOR
ADEOUATE NONE
5 ROOF
10 PLUMBING
GABLEIP
GAMBREL MANSARD
FLATSHED
ASPHALT SHINGLESLAVATORY
LWOOD JOIST
BATH 13 FIX.)
TOILET RM. (2 FIX.)
WATER CLOSET
IPELESS FURNACE -
rlL1R��� l
TILE DADO
6 FRAMING
II 11 HEATING
LWOOD JOIST
IPELESS FURNACE -
FORCED HOT AIR FU$
TIMBER BMS. d COLS.
STEAM
STEEL BMS. & COLS:
HOT W'T'R OR VAPO
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
GAS
j NO. OF ROOMS
OIL
B'M'T 2nd _
ELECTRIC
l�L 13rd I
NO HEATING
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This formis 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: Phone 62c--
LOCATION: Assessor's Map Number V (9-10 Parcell
Subdivision Lot(s)
Street ��Q, St. Number
Use Only************************
RECOMMENDATIO Z�. OS AGENTS:
Conservation Adm nis rator
Comments
romme-m—wir =4
Town Planner
Comments
Food Inspector -Health
Date Approved /
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Septic Inspector -Health Date Rejected
Comments
Public Works - sewer/water connections
driveway permit s %-M
Fire Department
Received by Building Inspector C r ti ml Date
i,
JUL 1 91996
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Growth Management Bylaw Exemption Statement
Town of North Andover Building Department
This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the
Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information
as requested below.
Name of Applicant on Building Permit (below) Address o Property for Permit (below)
Map and Parcel : Purp se of Ap ' ation (check below)
Phone Number of Applicant: ingle Family _ Two Family
I the undersigned applicant for the above property attest that the attached building permit for which this
form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth
Management Bylaw. I also understand providing this form does not absolve me or any party to this permit
from the requirements of obtaining other permits required prior to the issuance of the Building Permit.
Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building
Department and is only officially accepted when the Building Permit is issued.
Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the
above lot, in the building permit application and associated attachments, complies with one or more of the
following sections as indicated by a check mark.
This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in
existence as of the effective date of this by-law, provided that no additional residential unit is created.
The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning
Bylaw.
This application is for dwelling units for low and/or moderate income families or individuals, where all of the
conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is
restricted to senior persons through a properly executed and recorded deed restriction running with the land. For
purposes of this Section "senior" shall mean persons over the age of 55.
This application is a part of a development project which voluntarily agreed to a minimum 40% permanent
reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the
environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently
designated as open space and/or farmland. The land to be preserved shall be protected from development by an
Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism
approved by the Planning Board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with an
adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth
Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the
parcel.
This application represents a lot which is ready for building permits,(i.e, all other permits from all other boards and
commissions have been received and the project is in compliance with those permits), and the Development Schedule
does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per
Development until such time as the Development Schedule accommodates issuing building permits. Applicant must
supply approved form U with this EXEMPTION.
Please provide any and all information that would assist the Building Department in making a determination
that your application is allowed one or more of the above EXEMPTIONS.
By signing below I attest to the accuracy of the information provided and that the attached building permit is
allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or
inaccurate information, or the checking off of an above item which does not comply, whether done to my
knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit.
Signature cFf OWner or Authoriz6fd 04ent wh signed the Attached Building Permit Dg to
This form must be attached to the Building Per it upon application for such permit.
4
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'CERTIFICATE OIF USf &OCCUPANCY
Town of North. Andover
Building Permit Number 35 Date November 21 1996
THIS CERTIFIES THAT
THE BUILDING 10CATED ON 24 Peterson Road
MAY BE OCCUPIED AS -•SINGLE FAMILY DWELLING IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY,
CERTIFICATE ISSUED TO _H_; 11 s i de R a f t nrn
733 Tbrnpike S t .
ADDRESS Nor Anr�nvar Mq
,Building Inspector
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�(Q Office Use Only
uhe Tnmmnnwralt4 of filtt000l husPfts Permit No.
IlepaPtmint f]f Itubli[ *afttq Occupancy & Fee Checked
r'
a BOARD OF FIRE PREVENTION REGULATIONS 527 CIMR 12:00 3190 peave blank)
''•ate
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electricai Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date / 6 — AL SK
(M* or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street &N/umber) v 7 i�c�TPr-�nr.� rcr� 4 `cs w
.
Owner or Tenant '1 1,l/sf_d(9.
Cwner's Address
!s t!iis permit in conjunction with a building permit: Yes No (Check ApprCDriate °ex)t,�
Purccse of ?uilding 5J (a, 'b L---)-4 -1 It c Utility Authorization No. 10 2
existing Service Amos _� `Jolts Cvernead _ Undgrnd n No. of Meters
New Service u0 Amps /2rd! ZyU `/bits Cvernead _ Undgrnd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical 'Ncrx UA Jj4
No. of Lighting Outlets ; No. of Hot '--cs No. of Transformers K A
No. of Lighting Fixtures Swimming Psot 4ocve— 'n- —
grr.c. _ _:r.c. _ Generators KVA
INSURANCE COVERAGE: Pursuant to the recu,rements of Massacnusens 4erera! Laws
I have a current Liaoiiity Insurance Policy inc:ucirceiec Cceravcns Coverage or its substantial ecuivaient. YES VO = I
nave submitted valid proof of same to the Cffice_ YES NO = J you nave cneckcov
eci YES. please ineicate :he type erage by
checking the app oortate box.
INSURANCE BOND = OTHER = tP!ease Scec:`:)
(Exoirauon Date)
Estimated Value of Electrical Work 5
',Mork to Start 16 - ,IS ` 26 !nscec::cn Date Racues:ec: Rougn Wy f� � �� F,nai
Signec uncer the Penalties of perjury! e- A
C / / /,
FiR'.1 NARtE '
L NC.
Licensee g�t t' (s J,_3 "V -AJC 2 Signature L!C. NO.
/ L�Bus. lei. No. 669"
Address /i�ct dsr lS.S�r; / e '�✓o �l�tr.ti/ Att. Tal. No.
—.—
OWNER'S INSURANCE WAIVER: I am aware that the Licensee cces not nave the Insurance coverage or its substantial eeuivatent as re-
curred ov Massacnusetts General Laws. and that my s:gnature on :his permit abpiicat.on •Halves this reouirement. Owner
Aeent
,Please check enol
'eiecnone No. PERMIT FEE 3 tVf' v
,.Signature of Owner or Agenn
t-65_5
No. of Emergency Lighting
No. of Receotacle Cutlets
No. of Cil 9urners
Sattery Units
`:e. of Switch Outlets
I
No. of Gas 3urrers
FIRE ALARMS No. of Zones
No. Detection ar.c
Initiais ting DevicesHea
No. of Air Cana.
No. of Ranges � tons
c n
JI
No. Oisoosats No•cr
of
Putmos ons K:J
No. of Souncing Devices
No. of Self Contatneg
No. of Dishwashers
ScaceiArea ^!eatinC 4'.V
` Oetagt:On/Sounding Devices
Local ;Other
Con ec-i
Connec::on
Heating Devices KW
No. of Dryers g
No. of "J c. of
I Low Voltage
No. of Water Heaters KW
S;cns ?a::as:s
! Wiring
No. Hyaro Massage Tubs
i No. of Motors 7otai HP
07HER:
INSURANCE COVERAGE: Pursuant to the recu,rements of Massacnusens 4erera! Laws
I have a current Liaoiiity Insurance Policy inc:ucirceiec Cceravcns Coverage or its substantial ecuivaient. YES VO = I
nave submitted valid proof of same to the Cffice_ YES NO = J you nave cneckcov
eci YES. please ineicate :he type erage by
checking the app oortate box.
INSURANCE BOND = OTHER = tP!ease Scec:`:)
(Exoirauon Date)
Estimated Value of Electrical Work 5
',Mork to Start 16 - ,IS ` 26 !nscec::cn Date Racues:ec: Rougn Wy f� � �� F,nai
Signec uncer the Penalties of perjury! e- A
C / / /,
FiR'.1 NARtE '
L NC.
Licensee g�t t' (s J,_3 "V -AJC 2 Signature L!C. NO.
/ L�Bus. lei. No. 669"
Address /i�ct dsr lS.S�r; / e '�✓o �l�tr.ti/ Att. Tal. No.
—.—
OWNER'S INSURANCE WAIVER: I am aware that the Licensee cces not nave the Insurance coverage or its substantial eeuivatent as re-
curred ov Massacnusetts General Laws. and that my s:gnature on :his permit abpiicat.on •Halves this reouirement. Owner
Aeent
,Please check enol
'eiecnone No. PERMIT FEE 3 tVf' v
,.Signature of Owner or Agenn
t-65_5
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Date ... 1..... ....%�....../..0
519
OtNooTe,h
F: oLp TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�,SSACMUS�
This certifies that ...... �.. `. e SAA . t
........................................................................
has permission to perform ...
. ....... .
wiring in the building of........,, C F, tT„�(
c... l.(..s..!..
Ln
at ........ ............................. . North Andover, Mass. o
Fee..i..7S...:.Jf-,Lic. No.Jam/ ........................................................
.
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
i'.
� Office Use Only q ��
uhr �UmUtUUwrttl tts ttt U59ii9 Permit No.
~ _ r �E}turtmErit ofuhl'ttufEtg Occupancy & Fee Checked 4
: 3/90 (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 [qJ
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 1 ` �s
Vi or Town of NORTH ANDOVER To the I spector of Wires:
The udersigned applies for a permit/tto perform the electrical /work described below.
Location (Street & Number) 44 1-1 �`7�f�^Ad r�(
Owner or Tenant YJ 11si0e Oe
Owner's Address 733 % Vo''1vP,, A 4), 111,191
Is this permit in conjunction with a building permit: Yes E--:r----No (Check Appropriate Box)
Purcose of Bulidina ��h �i�B /i�n9 Utility Authorization No. ,jd�
Existino Service Amos _J Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Sernce -- Amps 12:5LJ K� Volts Overhead L_ Undgrnd C No. of Meters
Number of Feeders and Ampacity Al Location and Nature of Proposed Electrical Work e -w
O Uv( !fes%i
S
�9
No.
of L:cni nc Out ets
No. of Hot Tubs
total
No. of Transformers KVA
Above,
In -
No.
of L:gnt)ng Fixtures
Swimming Poolgrnd. I
grind.
Generators KVA
No. of Emergency Lighting
No.
of Receotac:e Cutlets
No. of Oil Burners
Battery Units
No.
of Switch Outlets
I No. of Gas Burners
FIRE ALARMS No. of Zones
Total
No. of Detection and
No.
of Ranges
No. of Air Cond.
tons
Initiating Devices
No.
of Cisoosais
Heat Total
I No.of Pumps Tons
Total
KW
No. of Sounding Devices
No. of Self Contained
No.
of D snwasners
I Space/Area Heating
KW
Detection/Sounding Devices
No.
of Dryers
Heating Devices
KW
Municipal
Locai jj Connection' Other
No. of No. of
Low Voltage
No.
0 Water Heaters
KW
I Signs Ballasts
Wiring
Nn. of Motors Total
HP
OTHER.
INSURANCE CC.'ER.AGE: Pursuant to the reowrements of Massachusetts general Laws_
I have a current Liamitty Insurance Policy including Comp Cperations Coverage or its substantial equivalent. YES NO — I
have suomttteo vaud orcof of same to the Office. YES C NO - If you have checked YES, please indicate the type of coverage by
checK ng the aocro to oox.
INSURANCE _ BOND - OTHER - (Please Soecrty) (Expiration Datei
Estimates Value of Eiectn alll Work 5
WorK to Start �/ Inspection Date Recuested: Rough G—'¢i .�� Final
Signeo unser the Penalties of perjury: L V �9
FIRM NAfv1E (/V �L �� LIC. NO.
G,�; LIC: NO.
censee //�� �r'0�✓��� « Signature _; cj 9
/� 1 6, W ' " "' %�%� Bus. Tel, No. � � � s 6,?1/6
Aceress 247g 1-11410 Ila /�`
4h_ /1 ,ah Alt. Tel. No.
OWNERS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re
cuired ov Massacnusetts General Laws, and that my signature on this permit application waives this redu)rement. Owner Agent
(P!ease check one)
Telephone No. PERMIT FEE 5
Sionature of Owner or Aaentl Y•5 65
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Date ............ / ..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............................... :..A ...... I, ............... ......................
has permission to perform ..... ...... ......... ......... ..... Z.: .....
............
. . . ......................
wiring in the building of .... ......... ... . .. /
atZ ........ .. . . r.......................... . North Andover, Mass.
Fee.. Lic. ................ .. .T..R..I...... ...... .......
.................
INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File