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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ roo., ......... wp.(.�Y.o ... a. -a ..................................
has permission to perform ......
wiring in the building of .............. ............................................
at 2
0 .1 ....... North Andover, Mass.
Fee ..... Lic 'No. .9. 4 t.. ........
' 1�01
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A,�E �!CAL'INSip R.
Check # O(W
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Commonwealth of Massachusetts Official Use Only
Permit No. 7
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.]/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLEASE PPJNTININK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his oK her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant 'R -, I
Telephone No.
Owner's Address U4me, --
Is this permit in conjunction with a building permit? Yes 1:1 No Er (Check Appropriate Box)
Purpose of Building Z6 )W-e-�Iq-( Utility Authorization No.
Existing Service 2LO Amps iX 0 -2 i1t) Volts Overhead [�r- UndgrdE:] No. of Meters
New Service — Amps Volts Overhead [1 UndgrdF] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Ck,4jj,,_, M4jv �n-lv,04 2 gvp PA1164�
k P IV4 !;" I I
Completion of the followinz table mav be waived bv the Inspector 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-
grnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil gurners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pu p
in
Totals:
KW ...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Mun'c'PP' El Other
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. Hydrom ssage Bathtubs
No. of Motors Total HP
Telecommunications Wiring.
No. of Devices or Equivalent
OTHER: I
Attach additional detail if desired, or as required by the Iropectul 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 such coverage is in fo�ee, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [Z BOND [I OTHER F� (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: A LIC. NO.:
Licensee—
dw iz ti -.s e tn A -i-, vv j.:?n Signatur�:� LIC. NO.: F
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:O� 3-40 -25�5'5-
Address: tgft- 9"ri- D 1= we- -$4-kw tq H Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work require�s 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 F1 owner's
Owner/Agent
Signature Telephone No. FPERMIT FEE. $
(""d fo - (f- - / z -P,/�
I'd,
W
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washingto�n Street
Boston, MA 02111
"1�1- www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information — Please Print Legibly
Name (Business/Organization/Individual): 12 N1 In & PH N�0
Address: A
City/State/Zip: EA4w &/ Phone#:�!7P— 3 6
. I
Are you an employer? Check the appropriate box:
I. El I am a employer with 4. El I am a general contractor and I
_ ptnployees (full and/or part-time).* have hired the sub -contractors
2. EZI 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.]
I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F-1 New construction
7. [] Remodeling
8. E] Demolition
9. E] Building addition
I0.F1 Electrical repairs or additions
11. E] Plumbing repairs or additions
12.F� Roof repairs
13.0 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.
lContractors 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:
Policy # or Self -ins. Lic. #:
Job Site Address:
P I
?��dK
Expiration Date:_
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 ceylo under the pains 5qdpenaoies
r—
that the information provided above is Irue 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
IJ Contact Person: Phone #:
.
Date....
:K
0
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
.4 1) /— 5 ee-- o —
This certifies that ............... — e/./ ....... 5
............................................ ..... Y.
has permission to perform ..... .......
wiring in the building of .....................................
...............................................
at .............. 30 ..... J. ............... North Andover, Mass.
........ ...... . ... ... ........
3�3 e-
Fee..�A.- No--)N.?I-g� ........... .......... ... .........
ELEcTRicAL INSPECrOR
Check # c2y/ 7- 7,6z/
7336
Ir Official Use Only
N, (fmonweahk ol Maijac4aietb Permit No
KgREM4
2epaptment ol3ire Servicei Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICALNORK
All work to be perforined in accordance with the Massachusetts Electrical Code (MEQ 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPEJLL INFORZTION) Date:
- . City or Town -of- k)o er-,4- 31,0,vel-- To the Insp'ector'of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) \-3 a "/� �/ 1(d -
Owner or Tenant
\:7-o e-Dgd
Telephone No.979'- ,4
Owner's Address
Is this permit in conjunction with a building permit? YeSEI No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity
Overhead UndgrdF-J No. of Meters
Overhead -Und-grdF] No. of Meters
Completion of the following table may be waived bv the Inspector 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-
grnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burn ers
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Ve `at7u—M-5-71
Totals:
u m b e r
I
I T o n s
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
unicip, I
Local Other
No. of Dryers
Heating Appliances KW
i tems:�*
— .0 quivalen
0 t
No. of Water
KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or E5uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Felecommunications Wiring:
No. of Devices or Equivalent
OTHER: �;70
Attach additional detail ifdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 944# 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 such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [] BOND F1 OTHER [] (Specify:)
I certify, under the pains d penaltie� Joperjuiy, that the information on this application is true and complete.
FIRM NAME- LIC. NO.: /5-53 C -
LIC. NO.:
Licensee: Signatu
(Ifapplicqble, enter "em" i�!e license number li Bus. Tel. No.:,F�Od e'�W--11<41
Address: t&-. ZAZL, 1QY Alt. Tel. No. -
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. �SSCC
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) [] owner 11 owner's agent.
Owner/Agent -- -1 1
Signature Telephone No. PERMIT FEE. S J/�) - " I
Location
No. Date
TOWN OF NORTH ANDOVER
41
Certificate of Occupancy
$
+4
Building/Frame Permit Fee
$
C 14us
Foundation Permit Fee
Other Permit Fee
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
Building Inspector
25.()o PAID
Div. Public. Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and.2--partments having jurisdiction have been obtained. This does. no'forelieve
the applicant and/or landowner from compliance with any applicable or requirements.
"'APPLICANT FILLS OUT THIS SECTION
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LOCATION: Asseswes Map Number &Or
Lf SUBDIVISION
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PHONE_j Z �cg? 7 � - 7 f 3 j(
PARCEL
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Aft �WA*A**�*�****'A**A,*W** � **OFFICIAL USE ONLY***""*A***""�-0-0-* inames
NDATIONS OF T
v11 COWStRVATION ADMINISTR&OR
AGENTS:
DATE APPROVED
PATE REJECTED
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
K -`FOOD INSPECTOR -HEALTH DATE APPROVED --Ir
Z�R /ZL�
DATE REJECTED-
VVE-P44 INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS__ -5-e-&
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PUBLIC WORKS - SEWER1WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR _DAT
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
4SACH
This certifies that ...................... . ......
'I I/
has permission to perform
.. ... ..... .............
plumbing in the bui,ldings of Y .............
at .. .......... North Andover, Mass.
Fee.10441-ic. No.. . .............................
// -- PLUMBING INSPECTOR
Check #
6233
C
MASSACHUSETTS UNIFORM APPLICA
(Prbit or Type)
/1/0/-11 '4;ur
2L/2LDO�4 . D
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sulklingLocation ::>01,"1'4
New 0 0
PERMIT TO DO PLUMBING
t1h
OwnWs Nafm
—TYP0 Of 0 =upancy'
ernent Plans Submitted: Yeso NOD
m #1
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DOMMCEZOVERAM
I hme a cwmn JiMlity policy or ft u0slantial 9W -
F D ivalent which mOlts the requkenwft of MGL Ch. 142.
Yes No
If you have M PlOaft nuftate the type Coverage by checking the appropratte bor-
A liability bmwance policy I& 00W type of Wsdemnity 0 Bond 0
OWNM INSURMCE WAffift I am aware that the liemm" do" not haft the msmance I I I requww
by 001081' IQ Of the Mass. General Laws, and thm IPY =YmUwe an ft�W—M appikation waives this mquiremeM
SgnaWm of Owner or owners Agm owrm —., Check one:
Agent 0
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the bW Of 1111 W*wlefte and mat an Pkxnbft wo arml ftW"Ons
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