HomeMy WebLinkAboutMiscellaneous - 276 MASSACHUSETTS AVENUE 4/30/2018-4
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to perform ........... kf ....................................................
wiring in the building of ................ P-�- ...... 1-00b. ....................................................
.. .................................. Yurth Andover, Mass.
F e e., ..... Lic. No. Z-�c �IerNIKS-�P
I ,
'Check #
11982
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services r
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 (leave 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 PRJWT IN INK OR TYPE ALL INFO"A TION) Date: // A V ) f 1.3
City or Town oh. A Awbove & 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)
Owner or Tenant b v
Owner's Address
zu M1
k OR %W)
Telephone
Is this permit in conjunction with a building permit? Yes 00 No R., (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Yolts Overhead F� Undgrd No. of Meters
New Servic Amps -Volts OverheadEl Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed fE
.Iec
. Wcpl Work_. ft
tl- J, 71 . . I I -
i —
No. of Recessed Fixtures
= G jut f" W6149
No. of Ceil.-Susp. (Paddle) Fans
1"Utt: M14y UU WU!VeU 2 Ine lEeecwr Oj W1
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generato KVA
rs
No. of Lighting Fixtafeg *L
swilarni
tt ergency Lighting
Ba ery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating evices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No, of Waste Disposers
amber
To
No. of Self -Contained
Detection/Alerting Devices___
No. of Dishwashers
Space/Area Heating KW
I Municipal
Local [:] Connection 0 Other
No. of Dryers
No—. —of Water
Heaters KW
Heating Appliances KW
0. of ---N I
0. of
Signs Ballasts
Security systems:
No. of Devices or Equivalent
Data Wiling:
No. of Devices or Equivalent
No- jjy&9Ma ss,%ge Bathtubs
No. of Motors Tot
Felecommunications wiling:
No. of Devices or Equivalent
OTHER:
-dumunat aetait u aestrea, or as requirea by the Inspector of Wires.
INSURANCE 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 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 offlce
CHECK ONE: INSURANCE 0 BOND [I OTHER [I (Specify:) 6141 //Y --
Estimated Value of Electrical Work: S, 06 11 - (When required by municipal policy.) (Expiration I
WorktoStart: 1#,,hlll __ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I cerdfy, under thepains andpenaldes ofperjury, that the informadon on this applicadon is true and complete.
FIRMNAME: STATtla'04 - U-L.WdAIZAL _ XNc— LIC. NO.: PM A
Licensee: IP k, I . --Jol A$V1VAJ!N SignatureD—.f I -JC. NO.: 7 qj.0 e
(If applicable, enter I exi�W 'in thilicense number line.)
Address: 110 0�6KSO%- OV Bus. Tel. No.�-
Tel. N %o,- A a e. %
011er Age
bility insurance co 093M�aly
OWNER'S INSURANCE WAIVER: I am awa e that the Licensee doaf not have the lia Alt
required by law. By my signature below, I hereby waive this requirement. I am the (che one) E:1 owner Q owner's agent.
Owner/Agent
Signature Telephone No. FEE: $
Aa,-Laoie 1-15--ly 4
R
TAe Cbmwitweafth ofmassitchmeft
Depaj*,mntqfInduYfrLdAcd&w&
Offxe Ofinv&W9MYORS
600 WashwgtonS&eet
.8&#om, H.4 021D
VWW.MWS.gO-Vhfta
Workers' Compensation Insuranm Affidavit: BuildersIContractors/FIectricians/Pluxuberq
icayatIfinformation,
Please Print Leziblv
Name �B.usinessjorganjzatjon&dmduaj)
Address:. 110 Ackjoto ST.
CitY/State,/ZiP: 10WO e1v M A Of Phone
Axe yon at% employer? Cheek1he approprintabox:
1. X am a employer wiffi ,
)r -T f
4. El I am a general contractor and I
e
emplaym (full-amd/or part-time).*
2,
2. E] I am a sole proprietor or paliner.
s 0'
ha-ve himd tw sab-contmetDn
listed cn ffie aMwjwd sbeet t
,b
sbip and hav8 no employees
4
These sab-contractars bave
gm
Worldug for me:h any capacitV.
Vlork=, camp. hmmce.
0
Ego work=' comp. insurance
S. We are a emporifim emd its
xequiredj
eq dj
M
3.11 am a homeowner doing all. work
officers have wommsed Iher
49M of emmption per MOL
qeM
Y.
y8em (No workew comp.
�I
L
c� 152, § 1(4), and we ban Ino'
N
mmmince requhrA] f
car
employees. [NO wa&nl
comp. fimmmw requireAj
T�pe Oproject (reqv6xed):
6. El Now conskmtku
7. [1 Remodeling
8. E] Demolfflon
9. F1 Buildi4g addition
l0-VBIeoft:Ioalzq-ks .dfitlons
11. M Plumbing rq%drs or additions
ME] Roofxepab
13.(] Off=
VUL rj--luuntmowmowmg&erwarboecowpwsaftonpaWnfixmdwL
tWaaffi&rikhdicdingdWamdoingaUwmkmdihenbim*uW&conbmtmsm on
=t lwftanew'affldwvitindicafts�ck
'-----stsffadwdanadM=d&haetsbow! -
-Taman
WWIOyertlWfsprovidingvorRejw'COMyenSaUDnimurancefo-PnVe?Mloyees Below IS thepOffCy andjob site
bIfOnnadojL
TUSUM08 COMPEMY
= 7
C
Policy#orseimmur,. #-., 08- WEC - CA 34014 EViration ]Pat-,-:.
Tob Site Ad&em A%o e- CWSWQ14.- R#,
Affacha CO I ------ I -------------------- z ----------
.py',Df the Worlmrs' compensation policy declaration page (Showingthe policynumber and expiratiou date).
Fail= to secare wymp as mqubmdurLder SecdOU25A of MOL c. 152 c4m leaft the imposifion of rdMIndpenayies of 9.
fine V tu $1,500-00 8U&or one-yearbVrisomment, as WOR as QM PenaNes ift the fD= of a STOP WORr, ORIDIR and a fine
ofvp to $250.00 a day against the violfftor. Be a(I-vised flIat a copy Of Ihis BW=entmaybe forwarded to the Office. o.I,
hmleftRt[Ons crfthe DIA. ft msurance, covM-agevermcafim
I
.1 do kere,6
Y
Ow
yafwandyenaNaqj�
ve*oytkat&einfonna*M.PrOW&daho,veivtweandco.-rect
Offlefalusee ozry. DO NOt 1PIft fu tft m'94, 0 Ae cOMS19ted AY dtY Or town offidd
City or Town: Pernaftuceasea
Xm&g Authority (cWe one):
1BOud OfHeRn I Mdtng Department 3. CitylTmn Clexk 4. Xleddeg hVector S p1mbfug lWfttDr
6. Other
colitactrerson:
10230
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that. -Z q0t) ..... � Atvff .......................................
has permission to perform ............... ..... a--.
plumbing in the buildings of..C.2.07& ..... /R -C .4-� .... ....
-1 �O k�Ct5% ... .... 4r A
at 4 .... A1.9= ....................... North Andover, Mass.
r......................................
Fee.... lhv.. Lic. No. d.01 .... 0 .......... .. .... ....................... ; .............
- I'
Check# PLUMIBING�I� SPECTOR
'�"-i %AXT I
Ivy -
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT#
JOBSITE ADDRESS tIA36- OWNER'S NAME
P
OWNER ADDRESS '=::�= AVF TEL FAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALA
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES[] NOD
FIXTURES -1 FLOOR- BSM
1
2 3 5 6 7
8 9 10
11 12 13 14
-4
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM JJ1 I
DEDICATED GREASE SYSTEM_ . ....... .
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTERIOR) L�J
!AITCHEN SINK
LAVATORY
-,ROOF DRAIN I __J —.--i 1 11
tHOWER STALL
—A
SERVICE / MOP SINK
TOILET J L'i
URINAL
A--------- j
WASHING MACHINE CONNECTION —J ------ - f
WATER HEATER ALL TYPES
WATER PIPING
OTHER ------------
L- JlI--
F-----'7, F-1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Ej
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNERE11' AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this 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 com of the
P
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE # SIG -NATO R—E- _j_
K4 P JP CORPORATION nJ #=PARTNERSHIP P-11 4: LLC
COMPANY NAME ADDRESS
CITY LL4i2"77i V) ISTATE ZIP TEL
FAX L EMAIL 11
CELL
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The Commonwealth ofMassachusetts
Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston., MA 02111
UV.- www.mass.gov1dia
Workers' Compensation 1usurance Affidavit: Buflders/Contractors/Electricians/Plumbers
IMMUM,
Address:
City/State/Zip: )L1,1q 5 In, K) plono e? 7d
Are you an employer? Check the appropriate box: Type of project (required):
1.0 lamae lover with 4. El I am a general contractor and I
.MP . 6. n Now construction
2Xemployees (fall and/or part-time),* have hired the sub -contractors 7 . . E] Remodeling
.Iam a sole proprietor orpartner- listed on the attached shoot. �
hip and'have no employees These sub -contractors have 8. E] Demolition
working formoinanycapacity. workers' comp. insurance.
9. n Building addition
[No workers' comp. insurance 5. El We are a corporation and its 10.D Electrical repairs or additions
recluired.1 officers have exercised their
3. [11 am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions
mys elf. [No workers' comp. c. 152., § 1 (4), and we have no 12.QRoofrepairs
insurance required.] t employees. [No workers'. 13P Other
comp. insurance required.]
!Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information.
T Homeowners who submit this affidavit indicating they dre doing all workand then hire outside contractors must submit anew affidavit indicating such.
!Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers I com
pensation insurancefor my employees. Below is thepolley andjoh, site
information.
Insurance Company Name:. .
Policy # or 8 elf -ins. Lie. ExpirationDate:
Job Site Address: City/State/Zip:
I
Attach a. copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure, coverage as requiredunder Section 25A of MOL o. 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. Do advised that a copy of this statement may be forwardedto the Officoof
Investigations of the DIA for insurance, coverage verification.
I do hereby certlo
ofterjury A at the infortnationprovided above is true and correct,
I -
Official use only. Do not write in this area, to be com
pleted by city or town offilcial.
City or Town:
Permit/Ucense N
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone
ffnformation and hstrueflois
Massachusetts General Laws chaptef 152requires all employers to provide workers' compensation for their einploye'es.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract. ofhire,.
express or impli4 oral or written."
An em
VoYeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore
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. 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 maLateriance, 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 11 1 shall withhold the issuance or
ic-ensmg agency
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 requ.ired."
Additionally, MGL chapter 15 2*p §25C(7) states'Weither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have b con presented to the cQntracting 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 cortificate(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 cany workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents f0i confrm]ation of -insurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be returned to the cit
y or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' .
cOM-POnsatiOnPolicy, Please call the Department at the numborlisted below. Solf-insured companies should enter their
self-insurance lic-ense number on to appropriate Eno.
City or Town Officials
-Please -be sure -that-the aff idavit-is -complete -andprinted'legibly. Th6Dbp-�tUbjitECspf6viddd�§p--i66--affii&-b'o--t't-o"m'"
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas ' e be sure to fill in the permit/license number whichwill be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in anyg'iven 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 ofthe 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 ii on file for future permits or licenses, A new affidavit must be filled out each
year. *Whore a homeowner or citizen is obtaining a license oi�ormit not related to any business or commercial -venture
(i.e. a dog license or p* ormit 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 shQuld you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone a-hd fax number:
The Com- monmalth of Mfassachwott�
Dqpartweiit ofladwtrial Accidents
ofiRce offilw8figatiom
600 WasUogtou fte,,r�,t
Boston, MA 02111
TO, # 617-727-4900 oxi 406 or 1-8,77�MASRAFE
Revised 5-26-05 Fay,# 617-727-7749
Date... ................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
'QThis certifies that
has permission for gas installation .....
. ............... ............ .........................
in the buildings of ...... .. .. ......... ........................
at ...... I ......... ...... Noyth Andover, Mass
Fee5b..t.,Q,. Lic. No. ..... ............ . .. .............
GASINSPECTOR
Check#
8938
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I e MA PATE I PERMIT# G�_
L4
JOBSITE ADDRESS �OWNER'S ME
b
GOWNER
ADDRESS Qa4lt 1� TE03jyj
TYPE OR
PRINT
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAX
CLEARLY
NEWO RENOVATION: REPLACEMENT: [3 PLANS SUBMITTED: YESF_J_j NOE]
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _j I
DRYER
FIREPLACE J _j I J __j
FRYOLATOR
FURNACE
GENERATOR ....... .....
,��GRILLE
INFRARED HEATER
LABORATORY COCKS E _31
MAKEUP AIR UNIT
OVEN _j
POOL HEATER
KOOM / SPACE HEATER'
ROOF TOP UNIT
JEST
UNIT HEATER —JI,
UNVENT�D ROOM HEATER ....... . . . . .
WATER HEATER
OTHER
01
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] BOND
OWNER'S INSURANCE WAIVER: I am aware that the licen ee 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.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the be of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliarkee–fth all Pert nent ov' i the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 1rT1q7—J& LICENSE QJQ 7LJI ISIGNATAE_ V
M MGF 0 JP 0 JGF LPGI CORPORATION D# =PARTNERSHIP [#=LLCE]#=
C MPANYNAMEISSM& If DDRESS
CITY STATE�ZIP ]TEL
FAX –11 CE EMAIL Cow M LE,
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The Commonwealth ofMassachusetes
Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govIdia
Workers'Compe-usation Insurance Affidavit: Buffders/ContractorsfElectricians/Plumbers
A Please Print Legibly
i2plicant Information
Name (Business/Orgaizationffndividual):, C2 a Z
Address:.15 nnu2fm j6t— )t�
City/State/Zip: 4— aone 7 7e D
Are you an employer? Check the approjJr1ate box:
Type of project (required):
1. El I am a employer with
4. Ell am a general contractor and 1
6. E] Now rNnstruGtion
employees (full and/or part-flme),*
have hired the, sub -contractors
t
7 . E] Remodeling
2 1 am a sole proprietor or partner-
listed on the attached sheet.
.
ship and'have no employees
These sub -contractors have
8. n Demolition
working for me in any capacity.
workers' comp. M*surance.
5. We are a corporation and its
9. E] Building addition
[No workers' comp. insurance
required.1
officers have exercised their
1011 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. 152., § 1(4), and we have no
12.E] Roofrepairs
insurance required.) t
employees. [No wofkers�
ad Other
comp. insurance reqairedJ
*Any applicant that checks box#1 must also fill out the section bel6w showing their workers' compe-risationpolicy information.
T Homeowners who submit this affidavit indicating they are doing all worYand then hire outside contractors must submit anew affidavit indicating such.
tcontractors that check this boxmust attached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy information.
I'am an em
ployer that isproviding workers I coin
pensation insurancefoT my employees. Below is thepollcy andjob site
informadon.
Insurance Company Name:.
Policy # or Self -ins, Lic. ExDirationDate:
lob Site Address,-, Citv/State/Zip:
Attach a. copy of the workers' compensation -policy ileclaration page (showing the policyntunber and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL o. 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 $250.0 0 a day against the violator. Be advised that a copy of this statement may be forwardedto the Officeof
Investigations of the DI& for insurance coverage verification.
I do hereby cerito un
,A( 17�pVlns andqenaltles ofperjury that the information provided above is true and correct.
0
Of
ficial use only. Do not.wrile in this area, to he completed by city Or town OffWal
City or Town:
permit/lAcense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. I'lumbing Inspector
6. Other
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. ofhire,.
express or implied, oral or written."
An ewloydis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoiut 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
dwallinghouso of another who employs persons to do maintenance, construction orrepair work on such dwelling house
or onthe grounds orbuilding appurtenant thereto shallnot because of such employment be, deemedto be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensmig 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 requ.lred."
Additionally, MGL chapter 15�, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance, with the insurance
requirements of this chapter have b cen pres ented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by chedldng the boxes that apply to your situation and, if
iiccessary� supply sub-contractor(s) name(s), address(es) and phone numbar(s) along withtheir 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 cany workers' compensation insurance. If anLIC orLLP does have
employees, apolicyis required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confitm]ationofinsurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be ratumedto the city or town that thic application for the permit or license is bedng requested, not the Department of
Industrial Accidents. Should you have any questions regarding the, law or ifyou 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 on to appropriate Eno.
City or Town Officials
-Pleasebe sure -that-the affidavit -is -complete -and -printed legibly.
ice of Investigations has to contact you regarding the applicant.
of the, affidavit for you to fill out in the event the Off
Please be sure to fill in the permit/Ecenso number which will be used as a reference number. In addition, anapplicaut
that riaust submit multiple pennit/licenso applications in anygiyen year, need only submit one, afff davit indicating current
policy information (iftecessaty) 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 maybe provided to the
applicant as proof that a valid affidavit ii on file for future permits or licenses. A now affidavit must be filleLd 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 orpiermit to burn 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:
Tho Commo a
DopafteiA Qfladwtdal Ac4dents
Of -ace off0estigatiom
600 Washingtoli fta
Boston, U& 02111
TQL # 617-72-7-4900 oyd 406 or 1-877,MASSRAF
Revised s -9.6-n.5 Fax # 617-727-7749
71
COMMONWEALTH OF MASSACHUSETTS
PLUMBERS AND GASFITTERS
LIUNSED AS A MASTER PLUMBER
ISSUES THE ABOVE LICENSE TO:
�JOHN, BARTLETT JR
13 NEWTON JUCTION RD
.�..KINGSTON NH 038,48-35,21
.11071 05/01/14 17505
a
0/23/2013 15:43 FAX 603 772 3246 Foy Ins.Group Exeter
00001/0001
CoORV CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDffYYY)
1 10/23/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such andorsoment(s).
_. PRODUCER CONTACT Nancy
J NAMF_- Bird CISR ACSR CIC
Foy Insurance - Exeter PHONE
(603)772-4781 (FAX, No,. (603) 772-3246
AC
64 Portsmouth Ave E-MAIL
ADDRESS:nanc.y.bird@foyinsurance.com
PO Box 1030 1
INSURER(S) AFFORDING COVERAGE i NAIC III
Exeter NK 03833 INSURER A Merchants Mutual Insurance ; 23329
INSURED INSURER 0 -Merchants Preferred Insurance 12901
JOHN 13ARTLETT JR PLUMBING INSURER C:Travelers Indemnity Cc
HEATING LLC INSURER D:
13 NEWTON JUNCTION ROAD INSURER E:
.KINGSTON NH 03848-3521 INSURERF:
CnVFRAr.FS (`r-RTIFIrATr_NlIURC0-MAat-�=v 11-11A OcIflalfw L1211mor
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
POLICY NUMBER
POLICY EFF
iMMIDD/YYYY)
POLICY EXP
IMMIDDAfM
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE M OCCUR
BOP9095194
5/21/2013
5/21/2014
15—
PREMISU (Ea occurrence) $ 500,000
MED EXP (Any one person) $ 15,000
PFRqONAI AAr)VIN.11lRY $ 11000,000
x additional insured
form HU 8555
GENERAL AGGREGATE $ 2,000,000
�G�EN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COMP/OPAGG S 2,000,000
[r
F__1 PRO.
X I POLICY I IJECT L1 LOC
$
AUTOMOBILE LIABILITY
COMBINE%,51NGLE LIMIT
(Ea acdd $ 500,000
BODILY INJURY (Per person) $
B
ANY AUTO
ALL OWNED F:;-r7l SCHEDULED
AUTOS AUTOS
aAP9116971
5/21/2013
5/21/2014
BODILY INJURY (Per accident) s
NON -OWNED
X HIRED AUTOS AUTOS
PROPER AMAGE
(P., . ID
id $
BRDEN $
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $
L:LDED
I I RETENTION$
$
C
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERtMEMBER EXCLUDED?
(Mandatory in NH)
Wescribe under
D RIPTION OF OPERATIONS below
NIA
3.A STATE NH
John Bartlett EXCLUDED
6JUB0616N03013
6/21/2013
6/21/2014
x I WC STATU- H-
TORY LIMITS OETR
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEH $ 100,000
E.L. DISEASE - POLICY LIMIT I S 500,000
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Rarnarks Schedule, if mom space is required)
Plumbing & Heating: Any Person or Organization including Certificate Holder is additional insured if
written signed contract, agreement, or permit to such exists prior to loss subject to form indicated
above in General Liability section.
%,cmiirik.,nec"WLUr_K k;AN(;LLLAFI0N
(978)688-9542
Town of North Andover
ATT Plumbing Inspector
1600 Osgood St.
Bldg 10 Suite 2035
North Andovez, MA 01845
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Foy, CIC/EXANCY
AGORD 25 (2010105) @) 1988-2010 ACORD CORPORATION. All rights reserved.
INS025 onionsi ni Tho A&fnDn nam� onfi i^m^ nr= iw#—ri marice #%f Annpn
0
49
Date -/e7 .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that
.............. ...... ..............
11
has permission to perform .....................................
plumbing in the buildings of ..................................
at ............ ........ North Andover, Mass,
P-LUM�-B/I'NLIG,/IlNi'SPEC*T*O*R
Fee �0. Lic. No.,','?
Check #
8475
r,
MASSACHUSETTS UNIFORM "PLICATION FOP, PERMIT TO DO PLUMBING
Crype or print)
NORTH ANDOYER, MASSACHUSETTS
Building Location —.13,6 e�jjfS
Owner alto
New Renovation
Date
Permit
Amount aZcee
Replacem�nt Plans Submitted Yes n No
(Print or type)
Installing Company Name_V
A A A- -9 -r- C-)� . AAA
Name of Licensed Pl=ber:
Check one: Certificate
C 11-1�- 7 rl -H nCorp.
Partner.
,0" Firm/Co.
Insurance Coverage: Indicate the t)w of insurance coverage by chmking the appropriate box:
Liability insurance policy EZ� Other type of indenmity Bond
usee of this application does not have any one of the above
Agent [—]
I hereby certify that all of the details and information I have submitted (or entered) in above application are trw and accurate to the
best of my knowledge and that all plumbmg work and installati erf
etts Ons P bru* under Permit Issued for this application will be in
compliance with all pertinent provisions of the MO'sac)us State PluMP4, Code and Chapter 142 of the General Laws.
P� 11 - �z .1
Type Of Plumbing Lic=se 1`0'
b,Am 12 A —7)
tOVM (OFFICE USE ONLY License Num= Master Jo=eyn=
t9s, 0-0
I
The Commonwealth of Massachusetts
Department of rndustrial Accidents
Office of Lnvestigations
00 Washington Street
. U1 Boston, M4 02111
www-mas&gov1dia
Workers' Compensation insurance Affidavit: Builders/Contractors/]Electricians/Plumbers
nnlir,qnf rnfnrma+;��
Name (Business/Organizafion/individual):
City/State/Zip: ' — �5� Phone#:
Are you an employer? Check the appropriate box -
1. 0 1 am a employer with — 4. 1 am- a gener I al contractor and I
employees (full and/or part-time).* have hired the sub -Contractors
I am a sole proprietor or partner- listed on the attached sheet
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. [1 We area cornoratin,, D"A
required.]
3. El I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
, nv R"�Ut th., �h_l I -
officers have exercised their
right Of exemption Per MGL
c. 152, § 1(4), and we have no
employees - [No workers,
cOMP. insurance required -3
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. F� Electrical repairs or additions
I I - 11 Plumbing repairs or additions
12.[] Roof repairs
,13.0 Other
on De sno,�rmg their, we,*,
y_rs� compensation Dobev information,
all work and then hire outside contractors -must -sub-it a new affidavit indicating such.
Homeowners who submit this ��I'a i'. eating they am doing 11�'
�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 employer that . isproviding workersy compensation InsUrancefor my eMployee& Below is thep
information. Oficy andjob site
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 M . GL 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 for . warded to the Office of
Investigations of the DIA for insurance coverage verification.
--------------------
It
I :doh;erehy;crunder ains andpenallies ofperjury that the information p7rovided a ov;s 71re and correct,
Si a e:
P4�ne
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 Hea�lth 2. B�uild:ingcy, Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other 11
Contact Person: Phone #:
M
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 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 contacting 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
insurance. 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 returned to the City or town that, the application for the permit or license lis being requested, not 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 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 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 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 Indusffial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 4106 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 vmm,.mass..gov/dia
Date .... 1–,9 .........
.... .............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... x
........................................................................................
has permission to perform....-... . ......................................................................
9 wiring in the building of
,:.... . ......
, I .................................................................
........ _vt`d� .... ........................... ............ . North Andover, Mass.
/2' "�?'a
Fee.' -/-5 ..... . . ..... Lic. No . ........... I .. .. ...... .........
....................................
CAL INSPEc-roR
Check # —1-67A-1-
5263
0
Jun 01 04 02:COp T
InspectionaI Services 9783460522 p.2
(2 /1
A I I f a C I Ujejjj
BOAF Fee Checked
�D OF RREPREVENTION REGU
LATIO�IS
OCIVL b!zink)
APPLICATION FOR PERMIT TO PERF RM ELECTRICAL WORK
AH wodk to b,� pCrj*Cj.-!jjCd ij! L,
.1c""S"s -*1 Cl)t C HE-), 5 2 7 C I R
CCk)1(-f-')1`CC wif;l 111C ML'ss'
(PLEASE Pi"UNT IN iN-K 01,! Y A! I". i�,VP'ORAI-1 7701V) Dn1c: �7
city 1,011,11 of:
By dlis appliraL 111SI)CC-101, of Pf wes:
ton the wi(jer�,glifd gi 5
Location (Sfreet 43-, Number) or !1cr imefflia i to pLrforni tile electrical work desc.ribcd below.
Owner Or Tcnallt
-1 Telephone No.� 9'9'-/0af5'(q
's 4ddrcss - - -----------------
Owner'
15 this perillit ill Celli a bwU"ii1- perwil?
J,uri)ose or :l;uiidi.0
Existilleu Service Ally!, Volts
New Service Amps
Number Qf Feeders anf A"nmacitv
Location znd -ature of Proposed Ricctrical Work:
.x
Yes No D (Check- Appropriate 130-C)
Utility Axiihoriz.,itiou llqo._
Overhead Uadord
b D No. of Alelers.
Ov,�rhc:id Urlde"rd —0 No. of.1-Meters'
No. Of RecEssed Fixtures
"I - —ic
of CCH.-Sasp' (Piddle) Fays
IfIDIP olay be waivc-(/ bV 1hC hi �Lcctcr of j Vircs.
TO t
No. Ugliting
1
4,
Tr.'11'15formers KVA
of tDutitis
Ne. of I -lo, 'Al'tjbs
G eacrators KVA
No. of Lifififing Fixtul-es
No. of Receptacle Outlets
At'Ove
sivilinaling 1001 "rnd. LJ d 'I'll
"U. 0 inergen,
Batten, Units
—Ril —fs� —oo
No. of Oil Burners
FIREALARAIS No.ofZoties
! i - �7� t, - 1N
F
No. of Switches
No. of"Gas Burners
Ni-7�f TRteci—loj)
2nd
Itilliatino Devices
No. of Ranoes
N o. of Ai- Cond.
Tons No. of A'ert*ua D.:.vices
No. of'Waste Dispo�ers
Heat
Totnis,
.... ........ K). of selr-con�alncd
- J Detectiun/Alertina Devices
No. orDis - Invushers
Sparei'Area Hezling
b
KNV Local Ll N1 611 jP I
CV1111 El otilel*
No. of Dryers
VIN -6-- C, r —NN, a t CT—
Heaters K W
No. 11.�-droninssage Ba�htubs INo.
lleaiinR Appliances
orAlmors
ct 11
01-curin, ;')Y51V11l-s:
No:ofP,?--.-ict-s 1�_�uiyilent
Data �Vlrltjg.
Ballasts rDevic;,
No. g, -s or quivileat
Tolal 11P —Tciccomni-,�M—cations NVII-�Ilg
I'llo. or Devicts or Eclulvaielit
OTHER:
C?r as req -1 -cd 0,,, Me laspector qj Wires.
INSUR.AINCE COVERAGE: Unless . wai-vccl by,"lic c:,,, i;er, no permit for tile perrorrfl-,jace of ek-ctrical Work may issue Unless
tile licensee proviules proof of liability 1115V'all.ce ilicluditig, "COMPICtcUl Wcrltioll" coverap or its substintial equivalent. The
I
uodersioncd certifies t1jaz 511C11 C()vcragc is in force, arid has exhibitcd proof'of same w the permit issuilig off -ice,
C-i-HECKONE: INSURANCE QIDOND E] 01TIER Ej (Spccify)
Estanated Value cf Elcctl-i�--z4l Wc.lk-:' (Wher; i-quired by mutticipal poiic,,.) (Expiralion Date)
Work to Sta-[: -a-11 l'IspLctiojis io be rcauested ill accorda,,ce withMEC Rul 10, ndupo completio
— L - f c a n
cerlify, UP ik'), 411 it . ;I ji'dile"Ir ell ofln-jury, thar the inforynalion Gil 116S aP1,11icalion is true and coinjulefe.
11-116 1 Pq Ai% I E: _,t 4e? LIC. NO.:
Licensee. 01 -.e Ure 1AC. NO .
Bus. Tel- No...
Address:
Alt. Tvl.
OWNER INSURANCE WAIVER,: nt be Lictl"Scc dWi Pcc 11,7"c tile insurancc coverage rjortli.111v
am (lie (C1'1':C'k',,;10 El o,'llcr 0ON11'1"cr'S3"CN.
I clephone N i).-- _R
j0WTh
TOWN OF NORTH ANDOVER
0.1
Certificate of Occupancy
$
CH
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee(;�,�
$ 00'
TOTAL
$
Check # vzq,�- 6,
17226
6-uilding inspe6&
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI!� RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
. . . . . . . . . . . .
BUELDING PERM[IT NUMBER: DATE ISSUED: 12- 2- Z10
SIGNATURE: 7
Building Com-missioEELN�2cstor of Buildings Date T—
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
6 -e -
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning Di;-& �d Proposed Use
Lot Area Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
454)
/0
I.Mater Supply M.G.L.C.410 1.5. Flood Zone Information:
Public _-44— Private D Zone Outside Flood Zone
1.8 Sewerage Disposal System:
Municipal OnSiteDisposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
-t:) -, 66 k64 Z-74. 44 +�5
Name (Print) ........... Address for Service:
Signature Telephone
2.2 Owner of Rec
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
wa -- 7,-� 5
Licensed Construction Supervisor:
0(0-130
License Number
AAdress
6-7 - (9 - 03
4i 40S
Expiration Date
Signat-a-re Telephone
3.2 Registered Home Improvement Contractor
Not Applicable D
: L, ?,,-p
7,6 4+
Company Name
Registration Number
-7 S,��
01- (3 os -
Add
L 6kc— �10-)
Expiration Date
e-
Signature Telephone
I SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 6 2506) 1
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 ..... X No ....... 0
SECTION 5 Description o Proposed Work (check
applicable)
New Construction
Existing Building 11
Repair(s) 11
Alterations(s) 11
P� 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
I* X Z"a
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
WFICIALUSE ONLY
F��
I . Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
Building Permit fee (a) x (b)
-4 Mechanical (HVAC)
-5 Fire Protection
-6 Total (1+2+3+4+5)
Ill
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, *D�e��Ile as Owner/Authorized Agent of subject property
t-N-M!b�authonze to act on
Myteh If in 11 ma. ers r o wo�horized by this building permit application
I _!21A�t� �0
Signature of Owner / / Date
-SECTION tL-GW'NER/AUTHORIZED AGENT DECLARATION
1, L s Owner/Authorized Agent of subject
property
Hereby declare that the statern nd information on the foregoing application are true and accurate, to the best of my knowledge
and belief
N
Print N
7A d -
S i a e of Owner/A ent Date
-NO. OF STORIES SIZE
-BASENENT OR SLAB
SIZE OF FLOOR TMERS iST 2 ND 3 RD
-SPAN
DEMENSIONS OF SILLS
DMENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIA.1, OF CHDANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and' or landowner from compliance with any applicable requirements.
man wannown
Lxj -7 k .7
APPLICANT PHONE I -
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION OT NUMBER
-----------
STREET
a 0 a a oaw....-w ... mass - STREET NUMBER Z —7 (o.
was a on a a a a was
OFFICIAL USE ONLY
masons 0 a 0 am* ISO a Mae
ATIONS OF TOWN AGENTS
06004"Mo
�5YR
own
won
a- rue
DATE APPROVED
CON ERVA*nnONAADMINIS
DATE REJECTED
TOWNPLANNER
FOOD INSPECTOR - BEALTIj
SEPTIC INSPECTOR - HF-ALTH
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
FIRE DEPARTMENT DATE
DATE
PfVh Al TUXT-PO
RECEIVED BY BUILDING INSPECTOR
TE
r
7he Commonwealth of Massachusetts
Di9partment of Industrial Accidents
Office of Invest1gadons
Boston, Mass. 02111
ftrke& Compensabon,Insurance Affidavit
Please Print
citt Phone # 2-S7)
I am a homeowner performing al work myself. ------ -
I am a sole proprietor and have no one worldng in any capacity
I am an employer providing workeW compensation for nTy employees worldng oncthisjob�
Company rrame., A
as mqLdmd mWet Seeffon 254or
arworoneyewe 11NIMINIffientA&VO&W.
uriderstmd #W a copy of blos statommt "my be formaxWto, the Office -of ftwesikjabom
Idaherebyowt
Sig rez
Print name—
Offickd use only
&0 PaOs and permAbs of pedwyhW && k*mmtfbn providLed above is fto aW coffea
do not wfte in Oft am to be completed by city or town offixiar
%W-40�
- (I U 2
FAMILY POOLS & PATIOS, INC. CSL #010330
sales *service - supplies RIC #118204
0 70 South Broadway, Lawrence, MA 01843 WC #4951074
T) Tel: (978) 688-8307 - Fax: (978) 688-1949 LIAB #C1098398230
SINCE 1978
Name _bgf(,9bq, �1� f) -
J - Date -1,SMA,4eAr
Address (9-7 --city P" -q, A,Vlv-lr StatelQ
- �Zip 0
-4,L
Home phone-11kilk-_205- Work phone -Cell phonejlj�: �ff- (Mb Add'l #
Cross street/directions
Estimated start date Estimated completion date
We propose to furnish and install one- )4)rn 2�(Z_C�d &,1, (0, CD) 0 swimming pool for
the sum of ( Af (, 0) .
THIS PRICE INCLUDES:
TOTALS
• Manual vacuum cleaner kit
- Leaf net
- 8 Ft Step,
• 3 -Step Stainless ladder
- Wall brush
- Handrail '54
• Rope & Floats
- Extension pole
- Filter
• Initial balancing chemicals
• 8 to 12 Wk supply of maintenance chemicals
- Test Kit
- Surface skimmer(s) Ol—
plumbed no more than 25ft from pool
- Pump & motor -71,4
-------
(supply depends on pool size)
- Coping Z&
I—
- Choice of liner
THIS PRICE ALSO INCLUDES THE FOLLOWING WORK TO BE PERFORMED BY A LICENSED ELECTRICIAN:
Bond and ground pool - wiring of a 220 volt filter pump - one 110 volt plug - wire and install one 220 volt indoor time clock - outside wiring
to be done in PVC pipe - sixty feet of electrical run from filter
(*note:, runs over sixty feet will be subject to an extra C S
IN AD6'ITION TO THIS PRICE, ADD ESTIMATED OF MACHINE TIME AT 0_3 EPER HOUR F4-,_a/0J'0
THIS PRICE DOES NOT INCLUDE: Initials
Any machine time in excess of that estirnated above.
Additional machine time to be billed at the same rate as above due with the second pool payment.
All hours of trucking will be charged at $ per hour per truck due with the second pool payment.
Any dumping costs incurred for disposal of ledge, large rocks, or soil - re -seeding of grass around pool - spreading of loam - trucked in water
- patio or fence around pool or any accessories except as noted below - additional fill, if necessary, for proper backfill or reshaping of hole - dis-
posal of large rocks - fuel connections - heater venting - fuel storage tanks - permits - damage to sprinkler systems or any buried items (ex.
dry well, electrical lines, cables, etc.) in the access and pool overdig areas - plumbing to filter in excess of 25 feet - stumping and/or removal of
stumps. brush or debris.
Water or soil conditions (ex. clay, peat, five sand, excessive rock, etc.) requiring a stone pack of the hole will be
subject to an extra charge of $_ &SUO minimum to $_A_L_i�maximum.
Use of the above mentioned stone pack will be at the discretion of the job supervisor.
Customers must supply access forall trucks and equipment.
It is the own _"s responsibility to obtain the building and electrical permits or to assume the costs of necessary permits. tO��Initials
Notes: 0 IJ J,.- re, _ acce-95
6P,TIONS
TOTALS
Diving board
Basic Pool Price
$
Main drain
Estimated Machine Time
Solar cover
Options
7- Dio
Pool light
Heater
Subtotal
?,?�o
Environpool Plus, 8 head
5% Sales Tax
37;L -
Caretaker w/Electronic Valve, l6hd
Additional floor heads
Total -4-
$___LZ9�
-5--a
Pqlaris Vac -Sweep
Less 10% Deposit
Polaris retrofit only
Balance of Contract
PAYMENTS: 113 EXCAVATION 1/3 BACKFILL + EXTRAS 1/3 SYSTEM START-UP'
The buyer hereby agrees to pay, in full, the total amount of this transaction upon start-up of the installed pool.Your salesman or job super-
visor will meet with you two to three weeks prior to excavation at which time all decisions including pool size, shape, liner print, and all options
must be final. Changes after this date will be subject to extra charges where applicable. You, the Buyer, may cancel this transaction at any time
prior to midnight of the third business day after the date of this transaction. Credit card payments not accepted on contract amount.
BUYER date 44 JKLOJ
SELL CR datecjApf\ Otf -BUYER date
CO
00
MASSACHUSETTS AVE.
1994 W Boston Survey S07-110
PREPARED: 12-28-1997
SCALE. I inch = 20 feet
CERTIFIED TO: MEDFORD COOPERATIVE BANK
ACCOK IM NG To FEDFRAL KNEW-KNCY MANAG.KMENT At' KNCY MAIN� THE
MAJORI�F! KhIKNTSON THIS PROPERTY FAIA, INAN AREA D&9IGNFDA8-
ZONE: 6,-,g�:Jpo�d
COMMUNITY PANEL -NO:
EFFECTIVE DATE;----- , Z , EL
NOTE. 7ONF '(:' ARE ARFM OF Millimm, FLOODING (NO SHADING).
THIS DESIGNATION Hi NOTBASED ON AN ELEVATION CERTIFICATE
JOHN
J.
RUSSELL
,03871�
0
z
From: Eileen P. Hat-, AAI At: Piazza Insurance Agency, a divisicin of HUB Int'l. FaxID: 9739880038 To: For Family Pools Date: lf2l/2004 11:25 AM Page: I of 1
AC -ORA CERTIFICATE OF LIABILITY INSURANCE OPI E DATE (MWDDM-M
DUCER ?0 37 01/21/04
The Piazza Insurance Agency THIS CERTIFICATE IS ISSUED -AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
C.i.McCarthy Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
299 Ballardvale St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wilmington HA 01087
Phone:978-4'74-4200 Lrax:978-988-0038
INSURERS AFFORDING COVERAGE NAIC ff
INSURED
INSUPER.b, CNA Insurance Co.
CF �U,-�-
INSURER -B A.I.G
Family Pools & Patio Inc.
70 S. Broadway
Lawrence Mk 01843
INSURER
INSURER D:
INSURER E
I COVERAGICS
T1r-E POLICIES OF IIJSURANCE LISTED BELOW HAVE BEEN ISSUED To T-iE INSUREC NJIAIFD ABOVE =OR THE POLICY PERIOD INDICATED NCTvv . ITHSTANDING
ANY REQUIREMENT TERM OR CONDITION OFANY CONTRACI OR OTHER DOCUMENT WITH RESPECT TC ftICH -HIS CERTIFICATE MAY BE SUED OR
WN PERTAIN, TFE IN-�URANCE AFFORCED BY THE POLIO ES DES �Rl ED -iEREIN IS SUBJECT -0,'LL -HE -ERMS. EXCIS'ID�S AND CONDITIONS
CF �U,-�-
POLICIES AGGREGATE LiMMSSHOWN IV-�Y HAVE BEEN REDUCED SY PAID CLAWS.
!Ns-
LTR.
INSR1
_TYPE OF INSURANCE
POLICY NUMBER
DATE (MWDD/YY)
7OUICTEXPRUMOW
DATE (MM/DD[YY)
LIMITS
GENERAL LIABLIT'i
EACH OCCURRENCE
61000000
A
X COIAMEPCIALGENERAL -LABILITY
C1098398230
12/31/03
12/32/04
LT;�F�l
:Ea oc-ureflo.)
-
S100000
= OLAIMS M,�DE 7X Occur
MED EXP (Anyms parson)
S 10000 —
X per proj agg / BI
PERSCNAL & ADV INJURY
S1000000 —
GENERAL AGGREGATE
s2000000
GENIL AGOREGATE LIMIT APF -IES PER
PRODUCTS - COMP/01' A33
62000000
POLICY I ERCT LOC
AUTOMOBILE
LIABILITY
A
ANY ALI-O
8414071
12/31/03
12/31/04
C01,4511JED SINGLE LIMIT
(Ea aociderr)
�1000000
ALL OW'qED AUTO,
X
SCHEDULED AUTOS
BODIL' INJURY
(Par person
X
HIRED AUTOG
X
NON-ONVNEr. AuToc
BODIL" INU;f
(Pqr acc;id�pti
PROPERTY CAI'VAGE
6
(par arcidanti
GARAGE LIABILITY
—
ANY AU -0
oil
AUTO ONLY.- EAACCIDE,IT
$
OTI-9� TH41 EA CC
$
AUTO 01-JLY AGG
G
EXCESSIUMBRIELLA LIABILITY
EACHOCCURRENCE
7 OCCUR CLAWS MADE
AQGPECA1'=-
DEDUCTIBLE
RETENT ON
WORKERS COMPENSATION AND
VV,; 6 1 A Ll- I I(-'IH-
EMPLOYERS'LIABILITY
1__JER
—EL.EkC�-ACCI')=NT
ANY FROPRIETQR-PARTIAERiFXECU-1,/E WC7481901 12/31/03 12/31/04
S 200000
01`�ICERIKIEMBEP EXCL�CED'�
Ifyes, dscriba unJer
El DISEASE - EA1. EVIP-Q (EE
5100000
SPH C Al- PR Cv 15 ONS o elm
E, L D ISEASE - POLIC Y'LIMIT
8 5 0 0 0 0 0
OTHER
00 IONSILO ATIONS /VSHItL'gS-J—EiZ�-Lusi—otjs-K5-Di-D Ey ENDORSEMGNTI SPECIAL PROVISIONS
L
e'.11CRTIFIrATIM
1 Ivil
NOXORT* SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOL.DER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABIILrrY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
- 1- -'-2, -41,
TION 1988
Jul 15 03 01:44p
C . . I ..' . I . --- Famjl�j po.l. & pat,as 9706801849 P-1
5GARD OF BUILI)IN(i ftr:f3UL.ATIC)M3
License. CONSTRUCTION SUPERVISOR
Number: CS 010330
81111104110:'07-1-19/1960
0'."9/2()05 Tr. no, 61
Reliftted: 00
WILLIAM C POULOS
70 S BROADWAY
LAWRENCE, MA. OIB43
071
0
Board Of'Buildin ' ��q (la". awbaJeA,
Repulations
One Ashburton Race, I M 1301
Uceneo: r, Boston 8-1618
-RVISOR LICENSE
QNSTRUCTION SUPC , Ma 0210
Number cS 010330 Exp . fres: 07,19,2005 Birthdate: 07/19/j...
RestliCted To.- 00
WILLIAM C POULOS
70 S BROAD'ArAy
LAWRENCE, MA 01843
Tr, no:
"'"P'OP for MOO and charigg Of address notification.
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Location
9 Date
No.
7--
0 40RTN
01 TOWN OF NORTH ANDOVER
ertificate of Occupancy $
Building/Frame Permit Fee $
Area
CH Foundation Permit Fee
Other Permit FeeU f2jqs 1.57
Sewer Connection Fee
Water Connection Fee
TOTAL
'��l ding Inspector
8-736 Div. Public Works
PERMIT NO.
8�-
le
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
(7?_�AGE I
MAP 4,40.
LOT NO.
2 RECORD OF OWNERSHIP jDATE
BOOK :PAGE
ZON E
S U B D I V.-CO—T NO.
'LbCATION
-RPOSE OF BUILDING
12- 6At
IOWNER'S NAME
10. OF STORIES SIZE
;��ER'S ADDRESS T_
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
ICUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOTALINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
,!,%,BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO IRI�QUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
SEE BOTH SIDES INSTRUCTIONS TT�ot& At�ga) M'&Q
PAGE I FILL OUT SECTIONS I - 3 (zo.
PAGE 2 FILL OUT SECTIONS I - 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
DATE FILED
SIGNATUR
OF OWNER OR AUTHORIZED AGENT
FEE
PERMIT GRANTED
7 Z-!$ 19 cls—�
3 PROPERTY INFORMATION
LAND COST
"EST. BLDG. COST
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
NUILDING
OWNER TEL. #
CONTR. TEL. #
IC #
CONTR. L
H.I.C. #
(�I( /I-,- .
T--) 1 0--- %4kb /
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY I S-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMIL��_�OiFoFkl'CE'S LO LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA -
APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION
_8 INTERIOR FINISH
3 1 2 13
PINE
CONCRETE
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
-6-RY —WALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. 8 M T AREA
14 1/2 1/1
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
CONCRETE
B
1
2
3
DROP SIDING
WOOD SHINGLES
EARTH
ASPHALT SIDING
ASBESTOS SIDI G
HARDW D
COMfAC;N
VERT. SIDING
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
CONC. OR CINDER BILK.
ATTIC STIRS. & FLgOR
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR OR
_�_D_ T—ONE
EQUATE I
5 ROOF
10 PLUMBING
GABLE
I HIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL SMS. & COLS.
HOT W T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
A
7 NO. OF ROOMS
_�iAS
OIL
B'M'T 2nd
lit 3rd
ELECTRIC
NO HEATING
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Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
I. ..............................................................................
has permission to perform .. . . .... . .......... . ; . ... ..
wiring in the buildin of ......... .... ................
...................... ...... —le ........
..... ....... 16 -IL -1 -
at .0 ... �4 ..... � North Andover, Mass,
.... ....... . ..... ......
Lic. No .......... .. ..... .......
Fee A .........
�Check , �) 7Y-�� ELECTRICAL INSPECTOR
5687
llwuuiviiyjuivyvEA"nqjriyitL3L3etw—"LI 110
DEPARTAIEWOFPUBUCSAFE Permit No.
BOAMOFFMPREVEMONRBGULAHONS5VaRnO
Occupancy & Fees Checked
APPLICARONFORPERMUTO ELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MtASSA S2STS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Datp
Town of North Andover
The undersigned applies for a perinit to perform the electricl work c
Location (Street & Number) 6 ///�q ZI 1 4,
Owner or Tenant /)01:1 '0 /-a, /7 /— C2 C /4 1
Owner's Address - -1 rT /71/1Z Ir
is this permit in conjunction with a building permit:
Purpose of Building
To the Inspector of Wires:
below.
No (Check Appropriate Box)
Utility Authorization Nol�
Existing Service Amp� �/P��olts Overhead rM Underground No. of Meters
New Service ;2toO . AmpSLL04-11,'Ovolts Overhead M"'Underground [:3 No. of meters
V
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work 6V -e 7�o :219,g4=4
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
0
Below
Generators
KVA
ground
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
F1
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
I
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OVER.
b=41r Ee QMrdW- RnM ID the ffP=XMlS dMffiMd1U9M CMU21 LaM
lbaNeaomalLitkba==R)Lykduftcmvi*ommfi=Covw,r.crbmbgzMa*Afft . YO NO
IhaNeaftiwdvafidpodcf=w1olhe0ffKn YES IfycuhawdrclodYESpkmffdc*de�pcfamWby
11SIS11-111,119M BOND r7 01M ft=SV*)
EqimdcnD*
E0n*dV"ofEkWcWWdk$
WOCkIDSM hpecbmDWeFMjesWd Roqgh FvW
5gried undcr-Tv PaA�s of pedw.
flRMNAME &44 Lk=No,
MOWER
oAriN�SUiSUP,ANMWAP4ER-,IamawmdutheL=wdoesmthmftism=aNer4pergsaksmWepydlmtasmgmdbyNbmdmemCtrnwLaws
anddafflysigramendis VrdM
pwritapoficab—'m , &WOMIfft
(Pleise check one) Owner 1:3 Agent M Te I lephoneNo. PERMIT FEE $
Or
signature of Owner or Agen
11M LUIVIAlulyryrd'"13 fir 1V2tU3,-V1L1"V 110
DEPAR73fW0FPUBUCS4M,V1Y
7 Pern-titNo.
BOAMOFFMPREVEMON
Occupancy & Fees Checked
o APPLICATIONFORPERMITTO ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MEASSA SSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover
ne undersigned applies for a permit to perform the electric I I work c
Location (Street & Number)
__ _
Owner or Tenant A I-ey /,
Owner's Address
Is this permit in conjunction with a building permit:
Purpose of Building
Existing Service Amps/L�o / Py&�Ivolts
New Service 1;21-9tO AmpszLo-/Z�-40volts
below.
No C]
To the Inspector of Wires:
(Check Appropriate Box)
Overhead Underground
Overhead Underground
"-" � I
Utility Authorization No.�,)
No. of Meters
1:3 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work I/ 0�1 ell, Vl' c-, 7-0 1=11,
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of lighting Fixtures
Swimming Pool Above
El
Below
ri
Generators
KVA
ground
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
0. of Disposals
No. of Heat Total Total
Pumps Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
1:1
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
I Signs Bailasis
Hydro Message Tubs
No. of Motors Total HP
YES 13 NO
loftoffim YES lfyoutv&drdzdYMpJwwm&*ftWofcomVby
BOND r7 OMM M ftm**)
EAni*dVairofEb=calWc& $
hp"mD*RqxsWd Ro* I Fulid
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Xm,os�,
PM?-ANMWAIVii�IarnmvmdUt[rLimwdonnothm
ondispwnkappbcafimw26.tsftmg*mw1
eck onne) Owner 1:1 Agent M
=00712144m%
Lk=No, 1381
f wls,01
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