HomeMy WebLinkAboutMiscellaneous - 29 FIRST STREET 4/30/201814
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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"
....... .............
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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�
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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.
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(Please check one) Owner 1:3 Agent Telephone No. PER MIT FEE $
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