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9,9 4 Date .... ..... ..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... ......... ......................
has permission to perform ...... k . .............. ................................... /,'-'
wiring in the building of ...... ...... ........................................
'at ...... .7
... .................... (..�.a ......... Ze .................. ..... . North Apdovei,
Vee..3
............ Lic. No . ............. . III.— .. ............. L)� ....... . . ...................
ELEcrRicAL 1�' ECMR
Check # -� 762
Commonwealth of.Massachusetts Ofucial use only
Department of Fire Services Permit mo-
ccu
pancy and Fee Checked
v 1/0
BOARD OF FIRE PREVENTION REGULATIONS Occupancy
71
v- 1/071 -Cleave blMA)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W
All work to be Performed in accordance with the Massachusetts Electrical Cod WQ 527 CAM 12.00 ORK
(PLEASE PPOWTMINK OR YTPE ALL IYFO r>
City or Town oh WjYY0N) Date:—
Dy this application the undprsl e 10 the _hnspector Wires:
Ives no cofhisor er iatention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunctio t a building permit? Yes No n B
Purpose of Building k I LDG PFRART ff
Existing Service Amps ����YOlt�sO�Verhea�d Utility Authorization No.
�Lew _Service Amps El TJndgrdE] No. of Meters
Number of Feeders and'Ampacity 1---YOlts OverheadE] UndgrdE] No. of Meters
Location and Nature of Proposed Electrical Work: ------------- e----
14401)
(Xky All
COELPIefion of thefollowing table may be waived by the Inspector of Wires.
No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. OiL Total,
NO. of Luminaire Outlets No. of Hot Tubs Transformers RVA
Generators KVA
Above o
NO. of Luminaires Swimming Pool mergency 19 ting
rnd. El Bot -toe Units
No. of Receptacle Outlets No. of Oil Burners
FIREALARMS
NO. of Switches No. of Gas Burners No. of Detect, n and
10
No. of Ranges No. of Air Cond. T I Initiatin Devices
rp- s No. of Alerting Devices
No. of Waste Disposers JLJLE;4L rump ........... .................... .. No. of Self -C
Totals: Detection/Alerting Devices
No. of Dishwashers $pace/Area Heating KW Local 0 Municipal E] other
Connection
No. of Dryers Heating Appliances KW Security Sysefe S:*
No. of Water U1 . No. of Devices or E ivalent
Heaters KW No. of Data Wiring:
Signs Ballasts
No. of Devic or Equ �alent
No. Hydromassage Bathtubs No. of Motors Total HP lecOmmunic tions wiring:
OTHER: or Equivalent
Estimated Value of Electrical Work: j Attach additional detail ifdesired, or as required by the Inspector of Wires.
Work to Start —A0 _iO2,a _ (When required bYnaunlcipal policy.)
-121 — I I InsPActions to be requested in accordance with NMC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless -'waived by the owner,
the licensee provides proof of liability insurance including no Permit for the Performance of electrical work may issue unless
"completed operatiov, coverage Or its �ubstantial equi v*alent. The
undersigned certifies that such c v, rage is in force, and has exhibited Proof of same to the permit issuing office.
V-11
CI-IECK ONE: INSURANCE MI BOND Ej OTHER E] (Specify.)
rcerttr
Y, under thepains andpenalties ofp h
fury, at the inforination on this application is true and comp,
FIRM NAM: ete
Licensee: Sil ature LTC. NO.:
(Yfapp11cab1e),,euytA -exe_Wt" in t1ye license numb line.) LTC. NO.:
Address: a Xpe a it r B�ns. Tel. No.
ect 7 Ork re�res � e t
*PerM.G. c.14
T �t of ]�Z S. Liren
Yr
ety "S" Licen
7, S. 57-61, security Ork requires Department of Public Saf Alt. Tel. No.:
OWNEWS INSURANCE WAIVE Ta, LTC. Nd.�.
-- — the Licensee does not have the liability insurance coverage normally
required by law. 13y my signatare below, I hereby waive this requirement. I aim the (check
Owner/Agent one) Elowner El owner's agent
Signature Telephone No.'
[ PE, UHT FEE. $
ELECTRICAL PERAUT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
1. ROUGH INSPECTION:
Passed — [�_� Failed — Re -inspection required ($50.00) -
Inspectors' comments: 4 /
y
(Inspectors' Signature - no initials) Date
2. FINAL INSPECTION:
Passed — f I Failed — Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initials) Date
3. UNDER GROUND INSPECTION:
Passed — [ ] Failed — f Re -inspection required ($50.00) -
Inspectors' comments:
(Juspectors' Signatare - no initials) Date
1 4. INSPECTION — SERVICE:
'-DATE CALLED NATIONAL GRID: NAM:
P"L 'L" �
P�a s �sse d -- f I Failed — f I Re -inspection required ($50.00) - f I
Insp cto
Inspectors' comments:
(Inspectors' Signature - no initials) Date
k5. INSPECI ION - OTHER:
5' SP
=ssed — Failed — Re -inspection required ($50.00) -
-0
ctors,
Insp-Eectors' comments:
sp
(Inspectors' Signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TELE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
j_/1. . -,,�
I'M. ) The Commonwealth ofHassachuseas
1K
Department ofIndustrialAccidents
Off,77ce ofInvestigations
60 0 Washington Street
Boston., MA 02111
1UV oww-mass.govldia
Workers' Compensation Insuranve, Affidavit: Builders/Contractors)Electricians/Plumbers
imlicant Information Please Print Legibl,
Name Q3.usiness/Organizatioivindividual):
Ad&ess:
City/State;/Zip;
Phone, #:—t) 0
ArO you an employer? Check the appropriate box:
1. n I am a employer with
4. 0 1 am a general contractor and I
employees (M and/or part-time).*
have hired the sub -contractors
2. El I am a sole proprietor or partner-
listed on the attac&d sheet. T
ship and have no employees
These sub -contractors have
working for me in. any capacit
workers' comp. insurance.
[No worke.Ts' comp. insurance
S. El We are a corporation and its
required.]
officers have exercised their
3.Ej. I am a homeowner doing all work
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type ofproject (required):
6. [J New constraction.
7. El Remodeling
8. E] Demolition
9. [],Building addition
10. M Electrical repairs or additions
11. [1 Plumbing. repairs or additions
12. F1 Roofrepairs
Un Other
�Any applicant that checks box #1 must also fill outthe section below showing their workers' compensation policy informatiorL
T Homeo,5mers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
-Taman employer that isproviding ivorlrers'compensadon insuranceformy enployee�. Below is thepollcy andjoh site
information.
Insurance Company Name: A."- I/ R -1 Ce -
Policy # or Self -ins. Lie. Expiration Date.--ja
Job Site Address --a City/State/Zip: IV I q 11 1�i T,-,,
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
flue up to $1,500.00 ancVor 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 ofthis statement maybe forwarded to the Office of
Investigations of the DIA_ for insurance coverage verification.
I do hereby c under th ep ains an dp en aldes ofv erjury th at th e information pro vided ab o ve is tru e an d carrect.
gr�y - IN I
OVI"Clal use onbi. Do not write in this area, to be completedby city or town official
City or Town:
Permit/License
Issuing Authority (circle one):
It. 13oard of Iffealth 2.33ufflding Department 3. CitylTown Clerk 4. Electrical Inspector 5. Pliumbing Inspector
6. Other
ContactPerson: hone
Locationo� C;fNf,)IL
No. 57) 6r A/ Date
'a.
,Z�1111111,
w1wMw
,!L +4 ,,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # 5.; 4q,
2 4 -4 �,j
Building Inspector
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16TI,
COMPLAINT NUMBER
DATE:
#59
AUGUST 8, 1994
COMPLAINTANT:DAVID BELYEA
CLOSE DATE:
Ao- 1n)9141 6T-
ADDRESS:27 MAIN STREET
PHONE: 352-2720 SON - JOHN
OWNER:CARONIS FUNERAL HOME
PHONE #:
ADDRESS:30 MAIN STREET
INSPECTION DATE:
ORDER L DATE:
COMPLAINT: UNPAID GAS BILL
- $2,000 -
BAYSTATE GAS CO. THREATENED TO TURN
OFF THE GAS. MR.
BELYEA IS
AN 84 ELDERLY MAN.
ACTION:
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