HomeMy WebLinkAboutMiscellaneous - 30 DAVIS STREET 4/30/2018Date ... ... /.!�=
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..................... lk't. L ( "..:t .......... S ........
has permission to perform ...... ..........................................................
le U
wiring in the building of ..... .................. ..................
at .......... �.P .... ............ S.� ................... North Andover, Mass.
f C— P— 0,
Fee L�.� ............. Lic. No. J.&S-L)3'4
....... .................... . .. ...
RI
EL I CA INSP
Check# 6-17,EZ-5
10851
Commonwealth of Massachuseffs Official Use Only
Department of Fire Services PermItNo,
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
.[Rev- Y071 (leave bl*)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrica ode WQ, 527 CNR 12.00
(PLEA SE PAWT) N MK OR TYPE ALL I NFOAAM TION)
Date:f1ekV 0101'a
City or Town of- NORTH ANDOVER To the-fn—sple-c—tor of Wires:
By this application the undersigned gives —notice ofhis or her i ion to p6rform the electrical work described below.
Location (Street& Number) 30 0,Lvis 614-eyr
: Ownii Tenant _3r V h. 0 1-> rz 's + TelephoneNoll 76-6,60-6%0.
2krl, 'Address
Is this Perm! ' t In conjunction with a building permit? Yes No A (Check Appropriate Box)
Purpose of Build*
mg — — — — — — — — — — � Utility Authorization No.
Existing Service Amps --volts
Xew Service _ Amps volts
Number of Feeders and Ampaciti
Location and Nature of Proposed Electrical Work:
N i
r 11 C, lk M 7- S -/�-ec v f ri I
of Recessed Luminaires
No. Of Luminalre Outlets
of Luminaires
No. of Receptsicle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
0. of Dryers
IN 0. ofWater
Heaters I(W
No. Hydromassage)3athtubs
OTHER:
Overhead El UndgrdE]
Overhead El undgrdE]
�No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming pool Above Ei In-
amd. gri
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. rv___
4
0.
El 110not_
0.
No. of Meters
NO. Of Meters
Fue
hr- -if
ro
be waived by the ector of
Total
rmers KVA
3rs KVA
ALARMS JNo. of Zones
of Alerting Devices
F1 other
Attach additional detail jfdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work.�%Ydo (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVER -AGE: 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 operation7 coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of s the permit issuing office.
CHECK ONE: INSLJRANCE�K BOND n OTEER [](Specify.) ame to
I cert!fy, ufider the ains and[enfles ofPeriliry that the in ation
421-4f ,
FIRMNAME: form. On this afflication. is trueand
co)'
J_� LTC NO. -
Licensee: Wtwh< Signature LIC - 0.
(1ir pp kable p in th�,Jicense nit er, line) N
a e e em t
/IVI" 0i L013672 Bus. Tel. No.;
Address
Alt. Tel. No.:
'Per M.G.L c. 147, s. 57-61, security work requiresDepartment fPublic 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) El owner D owner's agent.
Owner/Agent Y
Signature Telephone No. I PERMTREE.-
I 11kW
Ao. 016elf-U
Detection/All
Spacedria Heating 3KW
M11
Local El
Col
Heating Appliances )KW
ge- _�,Tity wst
No. of Dei
No. of No. of
Data Wiring:
SiRns Ballasts
No. of Del
No. of Motors Total HP
Te-lecommun!
No. of Dei
F1 other
Attach additional detail jfdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work.�%Ydo (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVER -AGE: 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 operation7 coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of s the permit issuing office.
CHECK ONE: INSLJRANCE�K BOND n OTEER [](Specify.) ame to
I cert!fy, ufider the ains and[enfles ofPeriliry that the in ation
421-4f ,
FIRMNAME: form. On this afflication. is trueand
co)'
J_� LTC NO. -
Licensee: Wtwh< Signature LIC - 0.
(1ir pp kable p in th�,Jicense nit er, line) N
a e e em t
/IVI" 0i L013672 Bus. Tel. No.;
Address
Alt. Tel. No.:
'Per M.G.L c. 147, s. 57-61, security work requiresDepartment fPublic 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) El owner D owner's agent.
Owner/Agent Y
Signature Telephone No. I PERMTREE.-
to 6.1 C()D=e:)
upp ectore Signature -no Mtials)
p Passed, Nalled—f I
l, �
hSPeCtOre CIDMMe)ItS:
Pate
MIMAL —INSPlluc
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YmPpecton' comments:
(rfis�ectors"qIgnaturB -)io Pate
IMPIR GRODM INgROCTION.
PaRsed—f I
hs.veetorsl Comments.
Cinspectors' Signahwo-m iuitfals) Pate
4
DATM, CAT tyrq —D W -U -10M. Offil DI:
Passed — f I
Lspectbrsl commeph:
Valled—
lassed — I I
q*ed MOM) -11
- Pu-speecors,
DOORTAGNAMTO.BF, 11-R 01—JT A" IMT ON RITE N TM A=A TO BE INNTECTEDIS NOT
--- ACCFSSMTFAMARF,)NSPFCTIOWO)T�$50.00-INTO-33YCMGFD. '
The Commonwealth ofMassachusetts
Ln Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston., MA 02111
UT. www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
NaMe (Business/Organization/Individual):
Address:'l 7 66 rccot ye 114
City/State/Zip- IV. W, 03 07 Phone It: 7.1
Are you an employer? Check the appropriate box:
1. [�R4 am a employer with 6
4. [11 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 I
-
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
3. 0 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. n New con.struction
7. F1 Remodeling
8. F1 Demolition
9. F1 Building addition
10.El Electrical repairs or additions
ME] Plumbing repairs or additions
12.E] Roof repairs
13.[i Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:.
Policy # or Self -ins. Lic. Expiration Date:
Job Site Address.1 0 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 requiredunder 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 here under thepains andpenalt�es ofperjury that the information provided above is true and correct.
'y 7, ML1 ) 7,;,, 2 d ( 2
Simature: Date:
Phone 172- 2 -
Official use only. Do not write in this area, to he completed by c4 or town official.
City or Town:
Permit[License 9
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
Information and Instruction's
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 employer4is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
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 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 subdivi - sions 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 contracting 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).uame(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 confurnation 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 is 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 �ppropriate Eno.
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 loc*ations 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 firtffe 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 p* ermit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations I 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 ofladustrial Accidents
Office of 111vestigations
600 Washington Street
Boston., MA 021 It
Tel, # 617-727-4900 ext 406 or 1-877�,MASSAFE
Revised 5-26-05 Fax # 617-727-7749
__WWW-MasS,9ov/dia
Date. .
I IONI TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that
...................
has permission for gas -installation
in the buildings of .............................
at North Andover, Mass.
Lic. No.
..........
GASINSPECTOR
Check # r,7�A'/
J.
MASSACIWSETM UNUDRNI APPUCATON FDR PERNIrr TD DO GAS FfrnNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date —S - 30-6c,
Building Locations 6 b�,Z, !S -k- Permit # 2,
Amount $
Nc's ar
1 Owner's Name evq
New Renovation Replacement 1:1 Plans Submitted
(Print or type) Check one: Certificate Installing Company
Name -Tee Pva"",)O" LL(- Corp.
Address 1-7 - P, A. Partner.
Qf�,J�"4, N�i rs-,-,qu,6�
Business 1. clephone 60.-3 -M:Z- S73-? Firm/Co.
Name of Licensed Plumber or Gas Fitter a=Q M -
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No
If you have checked yLs, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 121 Other type of indemnity 1:1 Bond 1:3
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this p
ermit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
I hi-rphv ot-rrifu thqt q11 �f tk� —A ; 1�-
—T—L-1111LL�U kk)l ujnuiru) in auove appucanon are true and accurate to the
best ofiny knowledge and that all plumbing work aa4-ft7-!;Nll,;tions performcd under Permit Issued for this application will be in
compliance with all pertinent provisions of the � rassac��e/, Statc,2pCode and Chapter 142 of the General Laws.
Title
City/Town
OVED (OFFICE USE ONLY)
Sianature of' Licensed Plumber Or Gas Fitter
0
Plumber
0 Gas Fitter License Number
Master
JOUrneyrnan
CO)
U
0
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2 N D . F L 0 0 R
3RD. F L 0 0 R
4 T 11 F L 0 0 R
5 T H F L 0 0 R
6 T H F L 0 0 R
7TH. F L 0 0 R
8TH. F L 0 0 R
(Print or type) Check one: Certificate Installing Company
Name -Tee Pva"",)O" LL(- Corp.
Address 1-7 - P, A. Partner.
Qf�,J�"4, N�i rs-,-,qu,6�
Business 1. clephone 60.-3 -M:Z- S73-? Firm/Co.
Name of Licensed Plumber or Gas Fitter a=Q M -
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No
If you have checked yLs, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 121 Other type of indemnity 1:1 Bond 1:3
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this p
ermit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
I hi-rphv ot-rrifu thqt q11 �f tk� —A ; 1�-
—T—L-1111LL�U kk)l ujnuiru) in auove appucanon are true and accurate to the
best ofiny knowledge and that all plumbing work aa4-ft7-!;Nll,;tions performcd under Permit Issued for this application will be in
compliance with all pertinent provisions of the � rassac��e/, Statc,2pCode and Chapter 142 of the General Laws.
Title
City/Town
OVED (OFFICE USE ONLY)
Sianature of' Licensed Plumber Or Gas Fitter
0
Plumber
0 Gas Fitter License Number
Master
JOUrneyrnan
Location 3 6) -t�A L) ( -Sz,
1-21 - 9'
No. Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
"*Y (�
66> 7 Building Inspector
1. 1 Property -Address:
,30 d�tt�
2.1 Owner of Record
1.2 Assessors Map and Parcel
J-6
Map Number
Number:
F,
Parcel Number
Name (Print) Address for Service:
66UZ-11, Qu,/4j(:2/
1.3 Zoning Information:
Zoning District Proposed Use
2.2 OvAter of Record:
219. -AR41Nd S�h:�ezl
1.4 Property Dimensions:
Lot Area (sf)
Frontage (ft)
1.6 WELDING SETBACKS (ft)
-SECTION 3 - CONSTRUCTION SERVICES
Front Yard
Side Yard
Licensed Construction Supervisor:
Rear Yard
Required Provide
Required
Provided
Reqwred
Provided
412
LA�
1.7%ter Supply M.G.L.C.40. 54)
Public 0 Private 0
1.5.
Zone
Flood Zone %formation:
Outside Flood Zone 0
1.9
municipal
Sewerage Disposal System:
0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNIERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
MR
Name (Print) Address for Service:
66UZ-11, Qu,/4j(:2/
Signat3jre el
2.2 OvAter of Record:
219. -AR41Nd S�h:�ezl
Name2rint Address for Service:
,I (� �� al �/
Signature Telephone
-SECTION 3 - CONSTRUCTION SERVICES
't.4 Licensed Construction Supervisor:
Not Applicable 0
Licensed Construction Supervisor:
License Number
Address
12—
412
LA�
Expiration Date
S,
Marc/ Telephone
-16
, f- 72 7
'0
3.2 Registered HAe Improvement ntractor
Not Applicable 0
/6),
Company W e
J.9-
10
Registra on Number
4�/
AdOress 01
j
Expiration Date
1 Signature Telephone
U0
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91
0
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90
0
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SECTION 4 - WORKERS COMPENSATION (RG.L C 152 § 25c(6) I
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 ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check allApplicable)
New Construction 11 Existing Building lff� Repair(s) [I T��Ierations(s) 11 Addition 0
Accessory Bldg. 0 Demolition 0 Other 11 Specify I
Brief Description of Proposed Work:
I
I SECTION 6 - ESTIMATF.11 CON-TRITrTION rn-MR I
Itern
Estimated Cost (Dollar) to be
Completed by permit applicant
OITICIAL USE ONLYI�l I I
1. Building
61Z�'
(a) Building Permit Fee
Multip ier
2 Electrical
(b) Estimated Total Cost of
Construction
Of
.3 Plumbing
Building Permit fee (a) x (b)
.4 Mechanical (HVAQ
-5 Fire Protection
.6 Total (1+2+3+4+5)
Check Number
ar,%-JL1%J1'4 14"VV11r,1MAUJLf1UK1kAJ1J[U1'4 JLUbhUUr4rLt1hVWt1E1N
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
'L&A�txlf--V LI -1 as Owner/Authorized Agent of subject
property L/
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
of Owner/,
? --3 -01-3
Date
NO. OF STORIES SIZE
BASENENT OR SLAB
SIZE OF FLOOR TRvIBERS is'l 2xr) 3 RD
SPAN
DMENSIONS OF SILLS
DWENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SL7-E OF FOOTING X
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
k
11�6
411
The Commonwealth of Massachusetts
Print
A2� eRWIld S21��es/7
06
city lyd /k� /I— Phone
F� am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensation for my employees working on this i ob.
Com ny name:
Address ST
`7
Phone* .--6efo ?
,-?L-
comnamf name:
Address
city: Phone
Pailure to secure coverage as required under 6ection 25A or MGL 152 can lead to
the InVOSWOVI of Crbylinal Penaltles.of a fine up to $ 1, ;W. 00
and/or one years' irnPrisOnment as well as civil penalties in the form of a STOP WORK ORDER and a fine Of ($100-00) a day against me. I
understand that a copy Of this statement may be forwarded to the Office of Investigations of the DLA for coverage %wdicafion.
do herby ceriffypder the pains and penalties of perjwy that the kftmabw provkbd above is true and coffect
Print
A�Is 1�
Official use only do not write in this area to be completed by city or town official'
OCheck AF immediate response is requked Building Dept
Contact person: . Phone #.-
VORKMAN'S COMPENSATION
9 -S -d-7
0
Building Dept
El
Licensing Board
El
Selectman's OfFice'
E]
Health Department
0
Ofher
CS # 022680
HIC# 103358
=,Vropoal =
A. J. Walsh & Sons
55 Pleasant Street
North Andover, MA 01845
# of
978-688-6737
or
1-866-AJWALSH
We hereby submit specifications and estim9tes; for:
............
............. ............. . . . . . . . ......
........ .. .. ...... .. - -
............. .. .. ... .....
..............
Cp
... . .....
............ ... ................ ...... ........ .. ... ........................... ........... ..
........... - . .......... ........... ... ..... ......... .
.... . ... .. ............ ..... .. .. ...
-11-11.1-1111.1-11 ........................... ........... .. .... ........... ...... ..
We propose hereby to furnish material and labor — complete in accordance with the above speQif
Xations for the sum of:
00
$ ey — Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents, or delays submitted
beyond our control. Note — this proposal may be withdrawn by us if not accepted within days.
Oftaptance of J)r
The above prices, specifications and conditions are satisfactory and are L --S �lgn at u re
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance Signature
&�NC3819 MADEINUSA
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Location
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No. j V3 Date �- 4 - 0 :-.1-
"ORTot TOWN OF NORTH ANDOVER
AL
0
Certificate of Occupancy $
Building/Frame Permit Fee $
MU Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 0
15858 q Aw ( (11-�
Building inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
or
BUELDING PERNUT NUMBER: DATE ISSUED:
SIGNATURE: zy��(
Building Commissioner/Inspector ot. Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
,3a �).4tlic=,
i.2 Assessors Map and Parcel Number:
5-6
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dia6d— Proposed Use
1.4 Property Dimensions:
L��ea Frontage (11)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
red Provided
+
1.7W&ter Supply M.G.L.C.40 54) 1.5. Flood Zone Inforination:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWi;itRS11IP/AUTHORIZED AGENT
2.1 Owner of Record
6 ru /I & 52—ce 16 r
Name (Print) Address for Service
&RT -,-V4,0
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
ZA, M �-s �g &,—,� F
Licensed Construction Supervisor:
-5 �—
61 (4, 44, u, 71 J4///
Ad" - *
(QAA�m —V7 3 Y 3
tur'T Telephone
Not Applicable 0
Cb e4j, (7 �13 6
License Number
//
Expiration Date
3.2 Registered Home Improvement Contractor
-1 A rrl L S A L5 LA,,f e /-
Company Name
ATIA
6 L/ ri t&- -S7- 5g /f 41 AAJ o$Geg
Not Applicable 0
Registration Number
Z ress
t o � , A. �0 3 —Y�
Expiration Date
:g"nat.re V Telephone
T
M
z
0
0
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G)
I SECTION 4 - WORKERS COMPENSATION (rvtG.L C 152 � 25c(6) I
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 ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
Existing Building 0
Repair(s) Z���erations(s)
0
F� tion 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
S A
V
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE. ONLY'
1. 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)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize -to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date L
NO. OF STORIES SIZE
BASENENT OR SLAB
SIZE OF FLOOR TIMBERS I ST 2 ND 3KO
SPAN
DfMENSIONS OF SILLS
DUvIENSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID �TR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Broposal rage ivo. Or Vages
1117
JAMES A. SWEET
Residential Roofing & Siding
46 Butler Street Salem, New Hampshire 03079
(603) 893-4342 (603) 893-1625
PROPOSAL SUBMITTED TO PHONE DATE
N -Ir. Bruno Szcelest 978-688-8960 �ujy 10, 2002
STREET JOBNAME
CITY, STATE and ZIP CODE
DATE OF PLANS
We hereby submit specifications and estimates for:
JOB
JOBIPHONE
2. Inspect all roof decking and renail where necessaryreplacement of any decking wiH be included
3. Underlay lower 6 ft. of roof edge , all valleys and around chimney flashing with Ice & Water Shield.
..5 ............ I-n.s.t.all-pew .8,,','..w.h.i-te.,,al.u.m.inum
. .... .. ...... .. . ...... ... .. . .... .. ... ................... qd
g .................................................. - ...................... ........................... - .......... .................................... ........................................
6. Apply new BP.Rampart 25 year Seal Down Organic Based Asphalt roof shingles to entire roof area.(dual Gray)
8. Remove existing attic static vents and existing power vent and cover holes with metal.
9; --- --Cut-existing-roof decking -2' --from,-centerhner--and"instaff, shingle- over -ridge -vents Appox"
10. Reseal all chimney flashing with plastic cement, using existing step and counter flashing. .
—W& �Wul 10 AA Wil AAL r'"t,16wa 0.
12. Remove all roof debfis from job site.
1. 1- ........................................................... --- .......... ............... ............ . ..................................... ............. ........... ...................................... - ............
13. 1wtaII 14 rectangular 6" X12" soffitt vents around structure.
Start time Is' part of September 02
We will require electrical vower.
We proPOSC hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
Riahmea fdwrona6eWleetipaied. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
Itur
involving extra costs will be executed only upon written orders, and will becc.,ne an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. e: This proposal may be
is prop
Our workers are fully covered by Workman's Compensation Insurance. withdr w y us if not accepted within
(Oays.
Aarlitancr of "roposal— The above prices, specifications
V
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: �-� / /, -//
1�1444!� - Signature
Date.. j.k. /.:7:. ��4 .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... 114
.............................
has permission to perform P.,c .........
wiring in the building of .... J61?L*.;o .................
at. ........................................ North Andover, Mass.
Lic.No...14 ............
C heck �CrRICAL INSPECTOV
10433
Common -wealth of Massachusetts OfficialUseOnly
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
(PLEASE PP.WTININK OR YYPEFALL INFORWTION) Date:
City or Town of: NORTH ANDOVER To the Inspector o
f Wires:
By this application the undersigned gives notice of his or her intention to perf6fin the electrical work described below.
'SO Oc-_�J`s sf,-,C�e_t—
Location (Street& Number) I
rTenant �>C'Jv\o Telephone Noy
Owner's Address
Is this permit in conjunction with a building permit? Yes No P�, (Check Appropriate Box)
Purpose of Building 'S0JJ t Utility Authorization No.
E31sfing Service 0 Amps 2- � 0 Z-0 Volts Overhead P5, TJndgrd F] No. of Meters
New Service — Amps Volts Overhead F1 Undgrd El No. of Meters
Number of Feeders andAmpacity
Location and NaWe of Proposed Electrical Work: 6f �-tw�c
k CC 5 er V � ce_ (I � 1�. f_rL tAtl-t r Jo C e rk cv'l
Completion ofthe following table may he waived by the Inspector of Wires.
No- of Recessed Lumina es
N o. o f C eff. - S
'usp. (Paddle)) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above In-
grnd. grnd. *E3
f Emergency Lighting
Battery Units
No. of Receptacle Outlets
lNe. of OLI Burners
F—ERYEALARMS
JNc. of Zones
No. of Switches
No. of Gas Burners
No -of Detectionond
][nitiating Devices
No. of Ranges
No. of Air Cond, Total
Tons
No. of Alerting Devices
No. of Waste Disposers
HeatPunip
Totals:
INyM��r
I
I Tons
TRW—
. .....
No.of Self -Contained
Detection/Merting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal Other
Local El Connection
No. of Dryers
'Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No..of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiri%cr:
Z,
No. of Devices or Equiv ient—
— —
OTHER:
cc .4ttach additional detail ifdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: Vo (When required by municipal policy.)
Work to Start: 16-31-1( 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 operation7' coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE V BONDE] OTHER F1 (Specify:)
I ceiWfy, under thepains andpenalties ofperjury, that the information on this aplication is true and complete.
FIRM NAME: M; L -L E LCCVv C 'ZIOC LIC. NO.: / 6 &3/5
Licensee: W '114 A IFL LAJ' �p t 1'� I - Signature'OLA W. A4:�� LIC.N046,g6 11
(If applicable, enter & exeopt " in the license number line) 1 19
Bus. Tel. No.- -3-769-`174
Address: 173 61^&4v &41 S -11M /J44't 030�1 Alt. Tel. No.:
--Per M.G.L c. 147, s. 57-61,security work requires Department of Public Safety 'IS" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage nonnally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner Ej owner's agent.
Owner/Aorp.nf I .
The Communwe-afth of Massachusetts
_z Department of IndustrialAccidents
I H61P. Office of Investigations
600 Waykington Street
MR
1, V14, Boston, MA 02111
WWW--qwss.go'v1d&
Wor
kers' COMPensatiOn Ins4rance Affidavit: Builders/Contr-actorsXler-.tricians[Plumbers
Please Print LegjbL
Nari�e (13.usiness/organization*/Individual):
Address':
City/State/Zip: Phone V
PAre you an ernPloyer? Che'
a
1. ck-the aPpropriate-box: -
I'Iim,*a employer with 4. F1 I am R general contractor and f Type of project (required):
em 0
�n 07
1 6. E] 'New coristructioh
emPloyees (full and/or part-time),* have hired the sub -contractors
2 -El I am.a.sole PrOPri0toror partner- listed On the attached sheet I EIRemodelmig
ship and. have no employees These su&contractors have OD I I ition-
working fior mein any capacity. workers' comp. insurance emo
We its 9. 0 Building addition
[No workers, comp. insuran r*.e 5. f are a corporation and
required.] officers have exercised their 10. 0 Electrical repairsor additions
or
aan
to
d�[
n
r additions
jtjons
ct
�io ]
'et
'olL
O'p r "Con *
Ty ew
6
trac rs
7 . R lode'�ng
'mc
oe 0 e 1,
v D mo -tion
0 0 a 10 -
9 E )3 j!dIng addition
ce. u i
at - cal repaIrs 0
i Its
]d 1 0 .0 Ele rl
Me r
I
313 1 din a homeowner doing all work right of 'exem'ption per MOL I I lumbm Tep
mYself [No-ihorkeirs'comp. 0 11 EIPI m ing Tepairs oradditions
I c. 1.52, § 1(4Y,'and we have no 1 0 f
insurance -required.] t 12.E]Roof n e'pairs
employees, [NO workers' Ot T
13.[].Otheer,
comp. insumce required-]
'Any applicant that checks bo)!#1 must So out the section below Showing their workeW bompensation poiicy in*forination,
t Homeownirs who submit this affidav 'ng they am dging allwork and then hire oulsi'de co
4contracton, it Indicar, M
t�at cheoc this box must Eftached an Wition,21 sh�ershowhn. the rEme ofthe sb., mractorsmustsub it anew Affidavit indicating such.
antractors Pod th Ir'
ch
aFA an eWloyer that is viding worJwrjJ# ... afibn.
AT iftsuranceformemployeen Below isa"'POlicy-andjobshe
informatiom compensadon
Insurance Company Name,
Policy 9 Or Self -ins. Lie, #:
Expiration Date:
Job Site Address: ------------
UY/Stafe/Zip.-
Attwh a copy ofthe workers'
Failure to secure coverage ' - ___1 - -- V-5- W -uw Ur, Lflep0licy numberand expiration date).
as required under SectiDn 25A of MGL c. 152 can lead to the imposition of cnminal penalties of a-
flne up to -$1,500-00 and/or one-year imprisonment, as well as civi penalt in f of a Top WORK ORDER and a fine
Of Lip to �250.00 a day against.the violator. Be advised that a copy I . ies the onn s
Investigations of th' of this statement may be forwarded tD the office of
e DIA for insurance coverage verification.
Offilciat use ()n
41. DO not WrLye & f -Us area� to L'6 WWF4ed hy chy' or town off, cial
Cfty or Town:
P- WIT '. U
Issuiog Authority (circle one): W U.Mae
I- Board Of Health 2. Building Department 3. City)Town
6. Oth6r Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone 0:
The Commonwealth ofMassachusetts
Department OflndustrialAcclde�ts
Office of Investigationg
600 Washin-gion Street
Boston, JPM 02111
www-mass.govldia
Workers' Compensation Insurance Affidavit: Builders/ContractorstElectricians[Plumbers
)Dlicant Ynfnrrn!Pfinin
.1
tLL E-Lec (,c co. c,
Nanle (Business/Organization&dividual):n� _LA)
Address:
City/State/Zip- Phone#
L : 603 -76 S- �7
re you an employer? Check the appropriate box:
I am a employer with 4- El I am a general c ' ctor and I
ontra
employees (full and/or part-time).*
2� 1 am a sole
have hired the sub -contractors
proprietor or partner-
listed on the attached shpt. I
ship and have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[NO workers' comp. insurance
5. El We aie a corporation and its
3. Erequired.]
l I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] f
employees. [No workers'
comn, surance re 11-11
Type of project (required):
6. E] New construction
7. EIRemodeling
8. 0 lieniblition
9. El Building addition
10. Electrical repairs or additions
11 - Plumbingrepairs or additions
12.0 Roof re�airs
13MO er ehk(Lq, VCWL-f
!Any applicant that checks b 11" J L `
T Homeowners OX #1 must also fill out the section below showing their workers, compensation policy infbrm�tion. .
who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Cc`ntract= that check this box must attached an additional sheet showing the name of the sub -contractors and their workers, cOMP. Policy information.
I ain an employer fil at is pro v1ding w o'rkers' eomp
inforination. ensation insurancefor Yny emPloyees- Below is thep011cy andjob site
InsuMnce Company Name:
Polic,J # Or Self -ins. Lie.
ExDiration Datea
Job Site Address
Attach City/State/Zip.kd i),,J e r
a copy 0 t e workers' compensation Policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required Wider 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 forni of a STOP WORK ORDER and a fine
Of up to $250.00 a day against the viorlator. Beadvised that a copy of this statement maybe forwarded to the Office of
Investigations of the DL,� for insurance coverage verification.
'doherehycert! under thepains andp�Enaltles ofperjury that the informationprovided above is true and correct.
,i nature: Date-
vi-liti use only. Do not write in this area, to he cojn
pleted by chY Or town official
City or Town: Permit[License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitYITOVVR Clerk 4. Mectric
6. Other al Inspector 5. Plumbing Inspector
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 1.52 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an em
ployee is defined as "...every person in the service of another under any contract of hire,
express or implied, ora� or wriften.11
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
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 apartihents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenan . ce, 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 forany
applicant who has not produced acceptable evidence Of compliance with the insuranc6 coverage required."
Additionally, MGL chapter 152, §25C(7) st�ies "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 contracting 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) andphone 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 a idavit may b submitted to a Dep e t of In'dustrial
hmatiori of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
Accidents for corif ff 0 th artm n
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Itidustrial Accidents. Should you have any q�estions rega�ding the law or if you are required to obtain a workers'
compensation policy.; please call the Depailment 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.'
1i , applications in any given year, need only submit one affidavit indic�ting current
that must submit multiple permit/lice se 0 In
Please be sure to fill in the Pelmit/license number which will be used as a referencei numb r. addition, an applicant
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 affiddvit.
The Office of Investigations would like to thank You*in advance for Your cooperation and should you have yquestions,
please do not hesitate to give us a call. an
The Department's address, telephone and fax number:
'M
"' Co"111no!'Meau-, Of 144assaenusetts
Depaftent of Industrial Accidents
Office of Inmfigations,
600 Washington Sire
,et
BQston; MA, 02111
Tel. # 617-727-4900 ext 406 Or 1-877�M-ASSAFE
Revised 5-26-05 Fax # 617,727-7749
COLONY INSURANCE AGENCY, INC.
22 HAVERHILL ROAD
P.O. BOX 538
WINDHAM NH 03087
Phone: 603-434-1962
Fax: 603-434-2634
Bill To:
James Sweet
46 Butler Street
Salem NH 03079
Invoice Date Agent Due Date
9/5/01 CGI 09/05/2001
Invoice
Invoice Number: 2047
Contact Code: SWEETJAM001
Agency Contact: ANNVILL
Effective Date Expiration Date
08/28/2001 08/28/2002
Type LOB Company Policy Number Reference Amount
NEW CGL ZUR SCP 38754603 Policy Generated NEW - Sweet, James $582.00
We appreciate your business. If we can be of further service, please $582.00
call our office.
All premiums are payable within 30 days.
North Andover Building Department
Tel: 978-688-9545
:1
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
So A /\ ).4 *1 lelo.A
(Location of it:acility)
Signature of Permit Applicant
�i�/ �,, 5� ?--
bate
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Ille ( 0 P/ 111011aw "I/W
mL\ Board of Building Regulations and Standards
Ci 4
HOME IMPROVEMENT CONTRACT OR
Registration: 117735
Expiration: 11/13/2002
Type: INDIVIDUAL
JAMES A SWEET
JAMES S�VEET
46 BUTLER'ST
SALEM, NH 03079 Administrator
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 017436
Birthdate: 11/09/1947
Expires: 11/09/2003 Tr. no: 19881
Restricted: 00
JAMES A SWEET
46 BUTLER ST
SALEM, NH 03079 Administrator
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BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Office Use �Cnly
Permit Na. 11fd
Occupancy & Fee C.11ecked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date 7 -
To the inspector of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Stneet & Number- 30 oavc-s 5—(
Owner or Tenant d/l/b 5 2 "fas 7
Owner's Address 0 JUR V, -S 5 7 –/
Is this permit in conjunction with a building permit Yes 0 No 4", (Check Appropriate Box)
Purpose of Building 12ul 4��I, -2y 6 Utility Authorization No.
Existing Service 0 Amps 2 2) —voits Overhead C3 Undgmd El No. of Meters
New Service —Amps voits Overhead 0 Undgmd 0 1 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work tj flyVI'6-7: -50 X -j-0 C T
17/? L: --n K 4�_ -S
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equival t YES NO
have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the Lty�pRecverage by checking the appropriate box
INSURANCE = BOND = OTHER = (PleaseSpecify)
(Expiration Date)
Estimated Value of Electrical Work$ C9 6-0. L) C) _0
Work to Start - �: - -j - � � Inspection Date Resquested 7 � —Rough Final
Signed undeith �Pna��es of pe-rl'u-ry:
FIRM NAME �1 -To y C_ r- LIC. NO. AL
NO.
Bus. Tel No. ('sa
Address- Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
�-6ry
Telephone No. PERMIT FEE S /'j
(Signature of Owner or Agent)
Total
No. of Ught8nq Outlets
No. of Hot fuse
No. of Transformers KVA
Above [2
In 0
No. of Lighting Fixtures
Swimming Pool gmd 0
gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Dioosal
No. Pumps
Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Soace/Area Heating
KW
Detection/Sounding Devices
0 Municipal 0 Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Baflases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equival t YES NO
have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the Lty�pRecverage by checking the appropriate box
INSURANCE = BOND = OTHER = (PleaseSpecify)
(Expiration Date)
Estimated Value of Electrical Work$ C9 6-0. L) C) _0
Work to Start - �: - -j - � � Inspection Date Resquested 7 � —Rough Final
Signed undeith �Pna��es of pe-rl'u-ry:
FIRM NAME �1 -To y C_ r- LIC. NO. AL
NO.
Bus. Tel No. ('sa
Address- Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
�-6ry
Telephone No. PERMIT FEE S /'j
(Signature of Owner or Agent)
) N2 1 A7
0
Date .........
TOWN OF NORTH ANDOVER 9
PERMIT FOR WIRING
8
Ui
2
This certifies that ........................... 10;
I I - --- '/ - - - - - ...........
has permission to perform--:� .............. .. ... ... . ... .......
wiring in the building of . �t .....
........... . ................................................. 4M
C>
.................................
at --Id� .......................... . North Andover, Mass.
..........
erfle
Fee..�O ..... . ...... Lic. Nd��Z.`�k ...............................................................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer