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HomeMy WebLinkAboutMiscellaneous - 29 FIRST STREET 4/30/201814 I 10243 "�+4 Date ... 4- . '? . Z- . - . / . ...... .. ... .... .. .. ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ 0 . ........ AVD..6 ................. has permission to perform ..... A�. (O'.o ............... .................................. 't2j6.*' g . ...................................................... wiring in the building of ............... ... at ��fl4l-les`l 5�7— ............................................................ North Andover, Mass. Fee ... L i c. N o. 9.5�.. ....... .... Mai" ....... ............. r beck # t�\ Official Use Only Commonwealth of Massachusetts Q UZXQIE� 0 Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS 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 (MEQ, 527 CMR 12.00 (PLF,4SE PRINT IN INK OR TYPE ALL 17WORAM TION) Date: 2ap / I / City or Town of. NORTH ANDOVER To the Inspector of Wi�es: By this application the undersigned gives notice of his or her intention to perfon-n the electrical work described below. Location (Street & Number) Owner or Tenant Dd:�� Owner's Address Is this permit in conjunction with a building permit? Yes [:] No 2' (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service IQLL Amps /p'b/.,�2olts Overhead Undgrd New Service Amps Volts Overhead Undgrd Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: & C-> ill eAe eAr k .:e lg-,� CoinDletion ofthe following table mav he waived hv the Invnermp of Wirpv No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of 7,0tal Transformers K -VA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above -Tn- El grud. Lwrnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I o. of Zones No. of Switches No. of Gas Burners No. of n nd Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: mber I.NY ................... I Tons I ..... . ................... IM ........................ of Self -Contained Detection/Alertina Devices No. of Dishwashers Space/Area Heating KW Local E] MuniciPF1 n Other Connection No. of Dryers Heating Appliances KW Security �ystems:* No of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Eouivalent No. Hydromassage Bathtubs No. of Motors Total HP TeTe—communications W1 No. of Devices or Equivalent ,OTHER: A ttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of�lectrical Work: (When required by municipal policy.) Work to Start: V;?3/ /I inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVER�.GE: 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 c2y�mge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [PI BOND[] OTHERE] (Specify:) I cerdft, under the pains andpenaMes ofterjury, that the inforinadon on this application is true and complete. FIRM NAME: 6 A 1-,, C�6 LIC. NO.: �,C3-70-5— Licensee. r3u,-1 an 4,0 Signature LIC. NO.: t--7 n--3 (If applica leInter exempt" in the license number line.) i V UM -1 Address: -5(- y Q,,yAA A-)(Y-VtN *Per M.G.L c. 147, s. 57-61, securiiy 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) El owner [:1 owner's 2,ent, Owner/Agent 7 Signature Telephone No. PERMIT FEE. S Me Commonwealik of Massackusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mas&gov1dia Workers' Compensation Imurance Affidavit: Builders/Contractors/Electricians/Plumbers Ail2licant Information Please Print Lembiv Name (Business/Organization/Individual):--.. CIO Ad&ess: 9(, '"A 0 1 Z-Phne #: ;T) Ltd S 0,6 9-S— city/statelzip Are you an employer? Check the appropriate box: Type of project (required): 1. M I am a employer with 4. 1 am a general contractor and 1 6. F] New construction ,employees (full and/or part-time).* 2. 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub -contractors have 8. E] Demol ition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. We are a corpomtion and i ts 9. n Building addition required.] ' officers have exercised their 10. F1 Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions myself, [No-workers'comp. c. 152, § 1(4), and we have no 12-F] Roof repairs insurance required.] t employees, [No workers' 13.0 Other comp. insurance required.] �Anyapphcant that checks bo)f#1 must also fill out the section below showing their workers'compensation policy information. Homeowner; 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. pol icy information. laman employertkat isproviding workers' coiVensadon insuranceformy employees. Below is Me policy andjob ske informadom 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 MGL 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u 4� aftks ofperjury that the information provided above is true and correct. g-? - Offleial use only. Do not write in this area� to be completed by city or town officiat City or Town: Permit/License # Issuing Authority (circle one) - 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date. / �. . -� !� �� ..... TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION This certifies that . . 4 1 ) �/ . ...................... has permission for gas installation u 1�� .................... in the buildings of .... ................................ at .............. North Andover, Mass. Fee ... .... Lic. No.. 9..e ..... ................. ; ........ GAS INSPECTOR Check # ( f 4. 5 411 . <�N— MASSACHUSE,TTS UNIFORM APPUCATION FOR PERMrr TO DO GASFMING *,�2) tPrint lypej IV =Jef'. Mass. Date JVJ Lf 7-CO3 ' Permit 0--, 49 Own Building LoTtion li-CZ ers Nam9&r. Dew / �w -&44ve- A. JQ le3rd::2 /9& Type of Occupancy, RESIT)CIVTIOL New r-1 Renovation r-1 Renlacement Pul"' Plans Subm ed* Yesr-, No Li Installing Company Name 2C)AeLe T AiA Ty) �Q, Check one: Certificate Address 30 0-0ACH1y%1qrj 4-Kf, El Corporation nip--7HUetj 01 k-1 0 C3 Partnership Business Telephone lo 92 -17 (7 -7 1 2-'Firm/Co. Name of Ucensed Plumber or Gas Fitter --� () a I- le T A- 5AMMI�7-t-jle(� INSURANCE COVERAGE: I have a current jobilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes &2' No E3 If you have checked Yes. please Indicate the type coverage by checking the appropriate box A liability Insurance policy 0", Other type of Indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licenseedoes not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner[] Agent 0 I hereby certify that all of the details and information I have submitted (or entered).in above application are true and acci rate to the best of my knowledge and that all plumbing work and installations performed under th Fjtued for this appli in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1421oFtel"tl nor Laws on T%of, L License: Plumber Whbture of IJ66nsed Piurnftror Gas fitter Title 1, fter or License Number 2�"own Journeyman 707FICE�N�L� 0 uj 0 '01 ui m Q .4 z 0 w LL a z U. 0 LLI .j z 4 cc cc 0 a 7 - LL 40 0 LL '01 ui m Q .4 z 0 w LL a z U. 0 LLI .j z 4 cc cc 0 No 2406 Date ..... ........................... P TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................................................................................... has permission to perform ...... ...... fviring in the building Of ..� ............ ............................................ ................... i,:�, North Awdover, Mass. at7i�2-. ... .. . ....... Lic. No . ............. ...... .................. Fee7;?-r .............. ................... ELECTRICAL INSPECTOR Check WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Or ri cc use orny DEPARTA0\T0FPUBL[CS4FETY Permit No. BOARD OFFNEPREVEMONREGbL4TIOAS 527CAIR 12.D0 19JA Occupancy & Fees Checked C2= -- APPLICATION FOR PERMT TO PEUORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTIUCAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date__2/2ZZO . a. Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perfbrm the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes E3 No (Check Appropriate Box) Purpose of Building . Existing Service [Z Amps lZb 22QVolts New Service Amps' Volts Number of Feeders and Ampacity Utility Authorization No, Overhead r-71 Underground No. of Meters Overhead ID Underground No. of Meters Location and Nature of Proposed Electrical Work V, T) 7 No. ofLighting Outlets No. ofHot Tubs No. ofTransformers Total KVA No, ofLighting Fixtures Swimming Pool Above Below 17 Generators KVA - - ground ground No. ofReceptacle Outlets No. ofOil Burners No. of Emergency Lighting Battery Units No. ofSwitch Outlets No. ofGas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. ofDetection and No.,pfDisposals No. of Heat Total Total Tons KW Initiating Devices No. ofSounding Devices No. of Dishwashers - - —Pumps Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTEER. Am 1. V-10 PRO M M 8, ...10 V- M. 1111fwMa" Ljoal= G ju A>-, df2 Lb=Nb I -so-, Adiu3s_ 14 Bushm Td Na AiTUNb. CgL OWMEIZ'SMURANMWAIVM-lamm=tbAftLx=domrd theM==wv=Wortsak&rWeqzvzk1tas raqLxWbyN4%m±&E& Caxd Lam "'V"Wuar-cnftpmnivpficmmw&,Ntsdflsm**Mmem (Please check one) Owner 1:3 Agent Telephone No. PER MIT FEE $ z 0 4� 0 z 0 w z 0 W w w " < z 2 w a IL UA ul z o 0 w Ic 0 6 z x x Z W z J L L o 0 z v; L z z a z i 3' 3: 1 U) w J 0 0 W, 1 W* w J I.. 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