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Date ... � 6 k7— � 1�
........................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
..... ..... ..................................................
has permission to perform
........... ........ .................................................................................
wiring in the building of ...........
........ . .. .... ..
at :t ... 2ci (Ioo,,-,A� A 2 r -j A -i- V
................................................................................................. rNorth Andover , Mass.
Fee ..... �V . ........ Lic. No.21cl�)
INSPECTO R
Check # 2 � 7 q t
Z MIM01111
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1 -,7 61 V?
Occupancy and Fee Checked
[Rev- 1/07] (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 PRINT 17V INK OR TYPE ALL 1NE,Of]k1AT1OA9 Date:
City or Town of. U,)-4 Va4-C To the Inspector of Wires:
By this application the undersigned gives notice of his or her �ptention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunctio with a building permit9 Yes X
Purpose of Building_ Piz /?k.,4 a / Util
Existing Service po() Amps /90 /p?t/6)Volts Overhead
New Service Amps Volts Overhead
Telephone No.
No R (Check Appropriate Box)
Authorization No.
Undgrd
Undgrd
No. of Meters /
No. of Meters
Number of Feeders and Ampacity f
Location and Nature of Proposed Electrical Work: e- /
Completion ofthe following table may be waived hv the Inspector nf Wiras
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
41
Swimming Pool Above Ei In-
grnd. grnd. E1_
lvo-.-OT Emergency Lighting
Battery Units
No. of Receptacle Outlets AD
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
4�!
No. of Gas Burners
No. or-D—et�ection and
initiating Devices
No. of Ranges
No. of Air Cond. Total'
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
J.Ngy!��Ejl!jq�
I..KW
..........
No. of Self -Contained
Totals:
1
1
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local Ei Municippi 0 Other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of Devices or Equivalent
No. of Water KW
0. of No. of
Data Wiring:
Heaters
Signs Ballasts
o. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
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 su h cov ra e is in force, and has exhibited proof of same to the permit issuing office,
CHECK ONE: INSURANCE W BONDE] OTHEREI (Specify:)
Icertify, under the pains andpeniddes ofperjury, that the information on this application is true and complete,
FIRM NAME- i?qAu 6*??� I LIC. NO.: QID-?3-,4
Licensee:- eym-) &iFtw Signature LIC. NO.:
(If applicable, enter "exeipot " in,4he I* nse numbyriline.) T78-5(ocl-777r
t U %f-1
4;� Bus. Tel. No.-.
Address: 7Z < ens,� n1ja Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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 F1 owner's agent.
Owner/Agent
Signature Telephone No._ FPE"I T FEE: $
r p
Th eCommon w-eaPth of Massachusetts.
Depaytment ofIndustrialAccidents
Office of lnvesfigatiDns
600 Washington Street
Bostoyi, MA 02111
www.masig.govldiar
Workers, Co)npensaLlonlusuranceAffida-vit:Builders/Contractors/Electricians/Plu-uibers
NaMe CBusine�slorganizationar4-viauj): . PCMAJ
Addr�ss: I J�_
uity/matca 4,�jr?�*W M,+. Phone
Are yon an employer? Check the appropriate box -
XI
am a employer with
4. F� I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. El I am a sole proprietor of partaer-
listed on the attached sheet
ship and have no employees
These sub -contractors have
worl�fiig for me in any capacity.
employees ?jad have workers'
[No workers' comp. insurance
comp. insurance.1
required.]
5. Fj We are. a corporation and its
3. F-1 I am a homeowner. doing all work
officers have exercised their
MYSeX [No workers' comp.
right of exemption per MGL
insurance reqi�recLj t
c. 152, § 1 (4), andwe have no
empjoyees. [No workers'
COIDT). insurance reauired-1
09
7 7S-
Type�ofprojectt (required):
6. El New construction
7- , El �,cmodeling
8. F1, Demolition
9. El -tuilding addition
I O.n FAectrical repairs or additions
11-ElPlumbMig repairs or additions
12 -El Roof repaks
13F1 Oth�r
*Any applicant that chwkA box *1 must aho fffl out the section below showing theit waikers' compensation policy information.
ljorneowners who submit this B:ffidavit indicating they are doing all work and then hire outside c r
outractors must siffimit-A now affidavit indicating sucI
lContractors that check this box must attached an additional sheet showing the name of the sub-contractorr and state whethcr or not those entities have
em&Yces- If the sub -contractors have rmployee&, they must proyide their workers' comp'. policy number.
1am an. EmPlOer that isproviding vorkets'conTensation insgramefor my enTjoyees. Belowisthepolicy andjob site
ifiform4d6n.
Insurimce Company N-�LmG:
Policy 9 or Set-ius.Lic. Expiration Date:
Job 8ite Address: 02�
_d10 ;kt citylstate/zip: -
Attach a copy ofthe Workers' compensation policy declaraition. page (showing the policy number and expirai�on date).
Failure to secure coverage as required undex Section 25A of MGL c. 152 can lead to the imposition of ofiminal penalties of a
fine up to $1,5 0 0.0 07 and/or o& -year impris onment as well as. civil p.enaltles in the form of a STOP WORK ORDER and a f 'm(, -
of up to $25 0.00 a day against the, violator. Be advised that a copy of this statement may be, forwarded to tfie Office, of
'Investigationg ofthe DIA for insurance coverage-veri&ation.
Ido hereby ce * ePAIT,
��ftdr th rs andpenalfies ofpedury that the lftfbrmadonproidd�d abDVLII is true an& -correct.
Sizaature: Date -
P L
hone 9: . 17
Officlar use only. I)o not write in this area, to he completed by city or town officiaL
City or Town:
Permit/License #
Issiflng Authority (circle one):
1. Boqrd of Health 2. Bufldkg Department, 3. City/Town Clerk 4. Electrical Inspector - S. Plumbing Impector
6. Other
Contact Person.,
Phone ff:
. .. .........
WRiETROF
,7
Location
No. C�q Date
TOWN OF NORTH ANDOVER
416 -
Certificate of Occupancy
$
Building/Frame Permit Fee
$
CH
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$ 1,o77,'�FO
TOTAL
C i1V t--.
06/11/% 1�. � ,bins
2�r 11077-50 PAID &V
2 Div., -iSuWc works
Location 2117
No. -? S121 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ 0
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
Sewer Connection Fee
Water Connection Fee
TOTAL
$ /00-
< --1,- 7
Building Inspector
Div. Public Works
Location Z-9
No. Z Date 7-A) -?C,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
�6/20/96 13:17 Y PAID
VL'
Building inspectof
Div. Public Works
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FORM U - LOT REIZASE FORM
INSTRUCTIONS: This form is 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 lawl
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: At, 6fm�c% Phone 4?!N3S,0_
LOCATION: Assessor's Map Number Parcel
Subdivision A061*4 (�k5 Lot(s) q
Street _(4/044'/ AM , St. Number ... 42�
************************Official Use Only************************
RECOMMENDATIONS OF TOWWAGENTS:
,00- / -A, 'I-1,0el
Date Annroved
conservation Administrator Date Rejected
Comments 25 V X"
1% — �/, ed - f
(tkz, tuL tm,,AJ` J11 iol ill vr 11i, - 3 bo bO
v 0 1 V
yl� cnftu_� Date Approved
Town Planner Date Rejected
Comments GY-)
,6AIA,)CU�LL-�
Date Approved
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CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number
THIS CERTIFIES THAT
THE BUILDING LOCATED ON
Date 7 X9 e
01
MAY BE OCCUPIED AS -L) O—Z :P IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS Ali MAY APPLY.
CERTIFICATE ISSUED TO
ADDRESS
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