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This certifies that
Date .... .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
'..*/.-.7.'f..�L ........... 14 --le .... . . .......................
has permission to perform ........ 71e—. 41e:'e? .......... ..........
wiring in the building of .........
at ..... 2 -� C' '4' ",
... . ................... ............ !�X ....... North And ve M
Lic.Nol�.2-1,1 ... ....... /
................. 4...
V, —� .................
Check # LECTRICAL INSPECTOR
Commonwealth of Massachusetts Official Use Only
I - . Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEA SE PRINT IN INK OR TYPE ALL INFORMA TION) Date: 111,41 ((
City or Town of. NORTH ANDOVER To the Inspevctor 61 res:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) C_,A., 0 9 ou JDAX S 5 LA,.,�q�
Owner or Tenant P4,15e—f—lov Jr- KD 0 S a Telephone No. kf 7-2�Ak6--
Ow n e r's Ad d ress 11 15:
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
PurpQse of Building 445S4,bSA--4^L— Utility Authorization No.
Existing Service _Amps —Volts Overhead El Undgrd EJ No. of Meters
New Rervice — Amps Volts Overhead El Undgrd El No. of Meters
P Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W% AX
Comoletion of the following table mav be waived bv the Insvector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ei In- El
1V5`.5TFm-ergency Lighting
grnd. grnd.
Battery 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
Initiatin Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
J.NyT��K].Tons
JKW
No. of Self -Contained
Totals-
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municipal 0 Other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. H�dromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
N Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value ol� Electrical Work: t �,oc)a, 1`8 (When required by municipal policy.)
InspectT ns to be requested in accordance with MEC Rule 10, and upon completion.
'4Work to Start: I k,& k %\ to
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 forc��nd has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE &KBOND [] OTHER [:] (Specify:)
I certify, under thepains andpenalties ofperjuiy, that the information on this application is true and complete.
FIRM NAME: LIC. NO.:,M 961 (c)
Licensee: ignature J----JQ LIC. NO.:6Z,:?i6e;`
(If applicable enter "exempt" in th license number line) Bus.'Tel. No.:14vs S 2'?-- )—Cplk
Address: ?VLA,6 &7-1,4 19*-VWA00* Z"& .,Ad 70 A76--iOtrof—
IJ Alt. Tel. No.: ?7 $C,
*Per M.G.L c. 147, s. 57-61, secLrity work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required
by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner 0 owner's
Owner/Agent
Signature Telephone No. FPERMIT FEE. $
0
a
I P
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Le2ibly
Name (Business/Organization/Individual):
Address:—?-, e
City/State/Zip: Wrhone #: 2 --
Are you an employer? Check the appropriate
box:
1. [S Klam a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 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. El We are a corporation and its
required.]
officers have exercised their
El I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comp. insurance required.]
Type �of roject (required):
6. ew construction
7. E] Remodeling
8. E] Demolition
9. F� Building addition
I0.E1 Electrical repairs or additions
I I. El Plumbing repairs or additions
12.R Roof repairs
131-1 Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: L-k-A*V 1j>,J CNIL, L A,�
X
Policy # or Self -ins. Lic. Expiration Date:
Job Site Address: -1-2 rkcvo !n� Citv/State/Zip: A)O, *,Z;;>D0V7<_,
Attach a copy of the workers' compensation policy declaktion page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisom-nent, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certW under the pains andpenalties ofperjuiy that 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#:
Date. /vOK/k .........
TOWN OF NORTH ANDOVER
MON
PERMIT FOR GAS INSTALLA
This certifies that . ./&/wl. "/. /I�rg�r .................
has permission for gas installation ..........
in the buildings of J�� . . 4C ..............
f 12,;,4 Pe.SS I lk-U
at .......... ?P .................... I NorthAndove,�, Mass.
Fee. AR��? Lic. No.
GASINSPECTOR
Check# A 77
7868
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:- MA. Date: /fl Permit#
Building Location:—C6 t/)/ Ow/ers Name:
Type of Occupancy Corn ional E] Industrial n Institutionk Residential
New: Er--Alteratlon: E] Renovation:
E] Replacement: E] Plans Submitted: Yes 0 No F�
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SUB BSMT.
BASEMENT
TTF—LOOR
2 N u FLOOR
3"D FLOOR
4 1H FLOOR
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Check One Only Certificate #
Installing Company Name:
4A
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El Corporation
Address: al.414
City/Town:—
�.01
&I'V11
State:
1
171 Partnership
Business Tel: kf -'? (
Fax:
El Firm/Company
Name of Licensed Plumber/Gas Fitter:
at�4e—1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 9/No 1-1
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity n Bond n
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.
Check One Only
Signature of Owner or Owner's Agent Owner El Agent
By checking this box E]; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
--l— — L.— 14— � Illy MljUWlVU!JtP ClIlU LIRIL dif piurnuing worK ano instaiiations perrormea under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
El PI "ber
2
Title VElas Fitter Signagre of Licensed Plumber/Gas Fitter
SI
M M
aster
City/Town Ojoumeyman License Number:
APPROVED (OFFICE USE ONLY) 0 LP Installer
.1
9 M,2: 41yl IV kh C If C, r, 3 a
Address:. El CorPoration
Ow'..': State:
Business Tel: EJ Partnership
ax:
Name of Licensed Plumber: El Firm/Company
INSU
f have a current Rg-b-11-ityinsurance policy or its substantial equivalent which meets the requirements Of MGL. Ch. 142 Yes PNo El
If You have checked Yes, please indi e the type of coverage by checking the appropriate box below.
A liability insurance policy. Other type of indemnityE] Bond
OWNER'S INsURANCE WAIVER: I am aware that t6 licensee does not h the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this pearamEIit! —ailu"ave
Pplication Yvalves this requirement.
Check One Only
Owner E]
a e ier or Ownees A en 1 0 gent EJ
A , EJ
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Ow' er
t 0 t c_ - - -
e" s n r - - 2Dt " �y
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11
Type of License:
�le
'Y/Town Uplumber signature 6f Licensed Plumber
04 Master
�JDROVE_a_—F—Fj----� E]JOUmeyman License Number: `7
(0 Grz
�USE ONLY)
NIJ 929 �IZ_715_06
9
MASSACHUSETTS UNIFORM APPLICATION
FOR PERMIT TO DO PLUMBING
City/Town. Vjj!�
MA. Date f
—7/0:� PernI'
Building Location.
--on
Owners Name:
41U
bc
�&
Type of Occupancy:
CommercialE]
EducationalEj InclustrialEl InstitutionalEl
ResidentialE�—
New: Rr""Alteration:
Renovation: E] - Replacement: Plans Subm . itted: Yes 0 No
FIXTURES
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9 M,2: 41yl IV kh C If C, r, 3 a
Address:. El CorPoration
Ow'..': State:
Business Tel: EJ Partnership
ax:
Name of Licensed Plumber: El Firm/Company
INSU
f have a current Rg-b-11-ityinsurance policy or its substantial equivalent which meets the requirements Of MGL. Ch. 142 Yes PNo El
If You have checked Yes, please indi e the type of coverage by checking the appropriate box below.
A liability insurance policy. Other type of indemnityE] Bond
OWNER'S INsURANCE WAIVER: I am aware that t6 licensee does not h the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this pearamEIit! —ailu"ave
Pplication Yvalves this requirement.
Check One Only
Owner E]
a e ier or Ownees A en 1 0 gent EJ
A , EJ
gZn'
Ow' er
t 0 t c_ - - -
e" s n r - - 2Dt " �y
1h a, nfo ve b 1 ��ee edl �e din th! �P.Pripca
qea h 0 an S e M.t, r r s '. P i ti.
e th atni.nr irl be ion c Hatrict, w el is'
m 'or r
lu r 0
er b y c 'iy 'of 0
L
K ed nd 'a .k .1d n d -r t e P -s df
no �POvi, 1, of h",ff, St a 2 C C t r Ot
e inen n the ab. te' ltbl,- o0dre nd hap eh 1e42 , he General Law
11
Type of License:
�le
'Y/Town Uplumber signature 6f Licensed Plumber
04 Master
�JDROVE_a_—F—Fj----� E]JOUmeyman License Number: `7
(0 Grz
�USE ONLY)
NIJ 929 �IZ_715_06
9
Date.. �ld. Y/. � �
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...
has permission to perform k"' 40
plumbing in the buildings of t, �'�d
at (4" / elo:� 5.5 ........... North Andover, Mass.
ic. No—/. 7 ..............................
Fee L
(-"& � qy - PLUMBING INSPECTOR
ChA # /R- (- ') -