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HomeMy WebLinkAboutMiscellaneous - 30 SPRING HILL ROAD 4/30/2018r 3 899 Th SA US Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . �-. -. -r ' ('. . . . 17� /v ............... has permission to perform ... //. T ........................ plumbing in the bu-ildings of . 5/M ...................... at . 3P. ....... North Andover, Mass. Fee. Lic. . ...... ID -.14. I f � PLUMBING INSPECTOR 12/28/98 14:35 25-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer • •- "•voa %%alert t%rt-L v,,%iiui`e Purl t-ma-iivsaa ,v ai-:: (Print or IM41 NORTH ANDOVER, Mass. Date _t0 Building Locatlon Owner'a Name New ❑ nenovation p neplacemerA Q/ Pians Submitted: Yea ❑ No ❑; FIXTURES �( one: `Installing Compsny Name ANDOVER PLG . & IIEAT I NG CO. , I NC. Corp. 2122 Address 573 112 SO UNION ST Cl Partnership LAWRENCE, MA. 01843 ❑Firm/Co. Uminess Telephone 508 685-8383 Nerne d Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE:ecx ope I have a current Ilabilty Insurance pollcy or Its substantW equivalent. Yea a No ❑ It you Have checked y_", please indicate the type coverage by checking Ilia appropriate box. A Itabllly Insurance poticy oy/ . Other type of Indemnity ❑ Bond ❑ Certincate OWNER'S INSURANCE WAIVER: I am aware that the licenses dost not have the Insurance coverage required by Chapter 112 of Ilia Mass. General Laws, " that my slgnalmo on this permit appllcation waives this requirement. Check one: Owner ❑ Agent ❑ nature o er or Omer s ani hereby c-ilty that aA or the details and inlormatlon I have aubmAl6d hr on(*(" In abo"a tion ua I ua and aoaNste to the best of my knowledge and that as plumbing wo+k and Initallattons Wormwd under the p mill I u*d br appks0on wfl be in ownpAance with all pertinent provti<lona of the MosaachuteNa State Phrrmbinp Code and Cheater 112 M tl"e ai line. Dy_ Title u! sty/Town A111T',TD IrYTx,E USE ON01 Ilcmia lkxnber 9983 Type of P4umbing Uconsa: Maslen Journeyman ❑ 106 a$=« V J t a eL ► y u r ~ a R 0 s a s .J N y e Y• i" U � a 1 a 414 W a A; )t N U e[ s M aL O a O Y a y R ►. at < 3r F' i a y X w er A y O i A Wo t O .. rx p Y; R aW A 06 W K Y N U Y F� a a h= O O o M o U 3 ae s • s w a S j s� 4 aU!—!lMT. !A![M[NT d lay FLOOR 3110 FLOOR 3RD FLOOR 1TH FLOOR aTH FLOOR OTH FLOOR TTH FLOOR •Til FLOOR �( one: `Installing Compsny Name ANDOVER PLG . & IIEAT I NG CO. , I NC. Corp. 2122 Address 573 112 SO UNION ST Cl Partnership LAWRENCE, MA. 01843 ❑Firm/Co. Uminess Telephone 508 685-8383 Nerne d Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE:ecx ope I have a current Ilabilty Insurance pollcy or Its substantW equivalent. Yea a No ❑ It you Have checked y_", please indicate the type coverage by checking Ilia appropriate box. A Itabllly Insurance poticy oy/ . Other type of Indemnity ❑ Bond ❑ Certincate OWNER'S INSURANCE WAIVER: I am aware that the licenses dost not have the Insurance coverage required by Chapter 112 of Ilia Mass. General Laws, " that my slgnalmo on this permit appllcation waives this requirement. Check one: Owner ❑ Agent ❑ nature o er or Omer s ani hereby c-ilty that aA or the details and inlormatlon I have aubmAl6d hr on(*(" In abo"a tion ua I ua and aoaNste to the best of my knowledge and that as plumbing wo+k and Initallattons Wormwd under the p mill I u*d br appks0on wfl be in ownpAance with all pertinent provti<lona of the MosaachuteNa State Phrrmbinp Code and Cheater 112 M tl"e ai line. Dy_ Title u! sty/Town A111T',TD IrYTx,E USE ON01 Ilcmia lkxnber 9983 Type of P4umbing Uconsa: Maslen Journeyman ❑ 3041 Date. ...... TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATIO '2SAC U This certifies that ............... V. - cc has permission for gas installation ................ CU ..4.. CU in the buildings of ... ............................ at .1 ...... ................ North Andover, Mass. Fee.,).� Lic. No.... AiINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO G ITTING (Print or Type) t NORTH ANDOVER. ,Mass. Date 71 lhuilding Location � j_ �iN(o tY�� Permit # o •� Owners Name i-l"erw- 5,#v New 77 Renovation n Replacement E Plans Submitted 0 �s FIXTUPrc 1-. (Print or Type) Installing Company Name ANDOVER PLG. & HEATING CO. , Address 57a -J/2 SO. UNION ST. LAWRENCE. MA. 01843 Business Telephone. 508 685-8383 Check one: Certificate IN .Corp. 2122 Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter GEORGE l AROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy i��Other type of indemnity Q Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not_ have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent i hereby certify that all of the details and lnfotmation t have submitted (of entered) in above application are true and accurate to the best of my knowledge and tl4at all plumbing worst and W(Aidations performed under Permit iuced for this application will be in compliance with ad peztinent provisions or tho Massachusetts State Cas Gude and Mapta 14: of the General Laws. .. By Plumber LICENSE: Plumber Title asfitter Signa re of Licensed City/Town: Master Plumber or Gasfitt•;er Journeyman 99R� APPROVED (oFFtcE USE ONLY) License )lumber r N O. V r = F- uusW a p7 W m 2 N tu 0 W to S W FO- in a j 4 N W a ul 07 N W O Z V d W tt: d7 CC !d C7 4 a Q O F, G N W S C� H 2 J t• Z 1. W N w O T k h W Z Q Q W } G G W, = r d y. N 4 Cd' 6 O O O Z_ W LU — O O N W S E' a ,tt O t1 U. >• Q a h- O StIQ-6StdT. BASEMENT IST FLOOR 2ND FLOOR 3130 FLOOR I ATR FLOOR 5TH FLOOR 6TH FLOOR TTK FLOOR aTH FLOOR (Print or Type) Installing Company Name ANDOVER PLG. & HEATING CO. , Address 57a -J/2 SO. UNION ST. LAWRENCE. MA. 01843 Business Telephone. 508 685-8383 Check one: Certificate IN .Corp. 2122 Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter GEORGE l AROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy i��Other type of indemnity Q Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not_ have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent i hereby certify that all of the details and lnfotmation t have submitted (of entered) in above application are true and accurate to the best of my knowledge and tl4at all plumbing worst and W(Aidations performed under Permit iuced for this application will be in compliance with ad peztinent provisions or tho Massachusetts State Cas Gude and Mapta 14: of the General Laws. .. By Plumber LICENSE: Plumber Title asfitter Signa re of Licensed City/Town: Master Plumber or Gasfitt•;er Journeyman 99R� APPROVED (oFFtcE USE ONLY) License )lumber r Location oe .) r 01-1%,- I No. Date I OWT#q TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ 14 Foundation Permit Fee $ Other Permit Fee PCX'/ $ TOTAL Check # Al -,91:96 17228 Building InspecEr/ J TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commiss' ner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 30 6,23� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required ovide R red Provided Required Provided /n 3L 3S2 P54) /O 7S` 1.7 Water Supply M.G L.C.40. 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Servi . O ignature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ 1j);A-au- (-I. Raids, 0330 Lic^e-nsed Construction Supervisor: O License Number 7 D Jif 19IY00LJGt),Cly + ��WHyl G2. Gi.fS. 6%��� Add s - ©? t) % Expiration Date tgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Pcn L 4- Rr,` 7'a 119-7,04 Company Name Registration Number ©L—/ 3— os" Ass d" Expiration Date l.�' 1�i Si nature Telephone M M X z 0 e V O Z M 90 l r s SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) 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 ...... A, No ....... 0 SECTION 5 Descrition of Proposed Work check all applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - F,STIMATM r0NSTR11rT1nN rnCTC I Item Estimated Cost (Dollar) to be Completed by permit applicant FFICIAVUSE ONLY ..:: 1. Building SZ/t� (a) Building Permit Fee Multiplier 2 Electrical ` (b) Estimated Total Cost of Construction 3 Plumbina Building Permit fee tel X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 ( —vo Check Number �r.I-i1UiN is UWtvr;K AU IHUK1GAllU1V TU BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT jffLvz-,�gun as Owner/Authorized Agent of subject property Hereby authorize �c—t ly PlAt d- f t,t, to act on behalf, i all matters relative to work authorized by this building permit application. J14r��� 3—iMc,-,' Q3 n�eof Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, CA' 1/ (1'1 N 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 167 67(,_. Iel Print \ 3—k vt ^ 0 �1 Signa ure of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TFVIBERS 1 2 ND 3RD SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT iSa 4- .%r 'L krA." el PHONE 9l k- Lp7" 716-F C LOCATION: Assessor's Map Number_ PARCEL 623 Z 09'- SUBDIVISION 7' SUBDIVISION LOT (S) P 'I I STREETS� r�^n� 1 ll id ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIS RATOR DATE APPROVED DATE.R� r ` l �fe —Cp c1.c t�-� fln ih �rrzin VlF �d O COMMENTS__C4V_an1n8 AIL J1,17 C 1, „ l 11 1 TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMME PUBLIC WORKS - SEWER/WATER CONNECTIONS _1]:1ly/114iNIi1 FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 Jim G The CofJe7 wmveafth ofala.=fiur= N1 i oepartn t OfFndustria[Accidertts Off= ofInvest7gations 600 Washing= 3 ma Boston, WA 02111 Work=' Compensation Insurance Affidavit APPLICANT INFORMATION r/ Please PRINT Lembiy Name: Lss 61 -} ►�li G..'"'lifir r Location:_ 0_� City' O"tk A -t1. �'�,4 Telephone #: C1 � �' ❑ I am a homeowner performing all work myself ❑ I am sole proprietor and have no one working in my capacity R11am, an employer providing workers' compensation for my employees working on this job Company Name: -i-A v►n ( �V �S �. PE."f1 `� Address: J 9Y -b City: C"e, Telephone #:. % 2:5 2`7 Insurance ComILL C ✓�L Policy #: G 10 311 q 2:3 U 1 D I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following. l: workers' compensation policies: Company Name: Address: City: Telephone #: Insurance Company: Policy Company Name: -- Address: City: Telephone #: Insurance Company Policy #: -- Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment 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 DIA for coverage verification. 1 do hereby cerWfv under the pains and penalties of perjury that the information above is true and correct Signature: i Date: 3 - 19—d 3 Print Name: rN 6 i Phone # �7 & f 4,307 - — r Official Use ONLY Do not write in this area City or Town: - Permit/Llcense #: D Check if immediate response is required o Building Department C) Licensing Board ❑ Selectmen's Office o Health Department o Other INFORMAnON & INS'1'RucnONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written, An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint 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 section 25 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, 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 beenpresented fo.the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the. Department of Industrial Accidents for.confirmation 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. - City or Towns 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. The affidavits may be returned to the Department by mail or PAX unless other arrangements have been made. The Office of Investigations 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.of Industrial Accidents Office of Investigations 600 Washington. Street. Boston, MA 02111 Pax # (617) 727-7749 Telephone # (617) 727-4900 ext. 406, 409, or 375 v .............. V-4, � p - I of ER FOO 1 MORTGAGE INSPECTION PLAN City/Town NorZT K P,.hJyoVER ,MA Date: S/ 7—Z/2 o Scale: \, _ (Z. c:; - Owner:— Owner: K R AM ER Buyer: SA6� LL P� Deed Ref. 'Z'� �, 259 Plan No. X119 Drawn per City/Town of t'iZ''+ Assessors Map 2-- N - N It5 . 43 SPRING HILL Rp To: k k-At>oa! e R P.. A.It-A K N e I hereby certify that the above Mortgage Inspection Plan was prepared for use in connection with a new Mortgage and is not intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge, walls or building lines. No responsibility is extended to the land owner, occupant or buyer. The location of the original building(s) as shown herein was in compliance with the local applicable zoning bylaws in 'efect when constructed, with respect to horizontal dimensional requirements, to lot lines or is exempt from violation enforcement action under Mass G.L. Title VII, Chap. 40A, Sec. 7,, unless otherwise shown herein. Subject buildings) lies in a flood zone designated Zone:_( and shown on FIRM Map Community -Panel # e> Dated: �� 2 "s',5 Job No. I= — Q. 44' o .0 JCD, INCORPORATED, LAND USE & DEVELOPMENT CONSULTANTS 4 AUTUMN LANE, METHUEN, MA 01844-3177 978-583-9932 K. Y AC—ORD. CERTIFICATE OF LIABILITY INSURANCE F C � DAai M � o PRODUCEn THIS CERTIFICATE IS ISSUED A 6 A MAOR OF INFORMATION ONLY AND CONFERS NO RIGH UPON THE CERTIFICATE THIS CERCATE DOES EXTEND OR C.J. McCarthy Insurance Agency, Inc. FAULT R THE COVERAGE AFFORD D BYT HE POUAMENDCIRS BELOW, CIO Piazza Insurance Agency, Inc. One Elm Square, Andover, MA 01810 INSURERS AFFORDING COVERAaE NAIL # NSURED_ INSURGq A: ('Djji =n9[1L8S44� QC1s , Pools & Patiq Inc. INSURERS: American Into --national Grow Fnrnil •• - . ll Cindi Gianopoules INSURER 0: S. Broadw$Y INFUAER D: _ .,, I Lawrence MA 41843 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERICO INDICATED. NOTWITHSTANDINI3 ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATrs MAY Be ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS POLICIES_ AGGREGATE LIMITS SHOWN MAY HAVE RF -EN REDUCED BY PAID CLAIMS, AND CONOITIONS QF,SUCH INSR MOD - POLICY NUMBER I LIMITS LTR 8R TYPE OF INSURANCE EFFYCTIM POLICY NwDDIYY _ DATE X' GENERAL LIABILITY I EACH OCCURRENCE is 1000000_ pR MI3E3 EapCCyrerlge?� F+ COMMERCIALGENERALLIABILITY XAn 01098398230 12/31/42 12/31/03 c 100000 CLAIMS MADE iz OCCUR � one MED EXP (Any Perin) $ 14000 R PD Ded $2A I 1000000 PER30NALdADV INJURY X Blanket Addl Ins. I GENERALAGGRfOATE s2000000 GENLAuGREG'7PRjATE ITAPPL1ESt'tR PRODUCTS - COMPIOPAGG $2000000 POLICY R JEGT LOC AUTOMOBILE LIABILITY A ANY AUTO TBb 12/31/42 12/31/03 C01,1211,X0 6114OLE LIMIT (E'=;[dem; 7:1 -2 on U cc 00 IL VI" C-6 >- C) �U) —j K O(DC) 0 (D <W a) LO n —0 Eo 3) C) N -2 NC14 Cl - cl ------ Cl cn CO D :7 U) C\l C's co mn C, +--) V) OC) —4 CLC cx (D LU a) It r--4 en CIS C) P5 7:1 on U 00 IL VI" C-6 >- C) �U) —j K O(DC) 0 (D <W n —0 cl ------ ------- C's > en P5 7:1 cow <-Jo�wcn� �ILL(Dr-- I 00 IL VI" C-6 >- C) �U) —j K O(DC) 0 (D <W n —0 cow <-Jo�wcn� �ILL(Dr-- I s wt c 3 WW�SS �S2 t kfl� U. i. M � ( 41 W i. to •o � .r: '� I i:1► ze • r, N y 000 0,9 g -�j d off, 6 �y �J p {{•CuCyJ! 1 1 - � O[ .6 • ter, N�� AV 1; �Q vv Dip �$ ob i�CV 'd'^.—r�r+r �D�N� 00rN OCa? 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O y � C CD cm I o� M O O rco CD m m t O� •d 3 10 O L C � O Q �Q E c c .Cc CL3 C Z ts CD O C C C O h 0 LU 0 U) LU U) w W W W ca • . 5 0 :•m c 0 0 C L O C V •dam . �V • d c C O O � CD o c n m C N �O E 42 H V C m J N A • O � N O O_ ZmO O Imm N a Of 0 aa O. C = m C3 Z `� o o ••. 8LC v► c •C H m H o D 3 0 N W co -0, A_ -==5 s .y ., c N ac 'E CL= 5 •N Z O CO)CM CL m� o ` O _ =�gJI.m5 m co O CD Lm O Z CD Q. O y � C CD cm I o� M O O rco CD m m t O� •d 3 10 O L C � O Q �Q E c c .Cc CL3 C Z ts CD O C C C O h 0 LU 0 U) LU U) w W W W ca • . Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING X..Cl ...... Aqw..1.0/ ......... This certifies that ...... R .. .... ............ ...... has oermission to perform .. ......... . .......................................... wiring in the building of ....... ............................. h at ... .3.0 ....... I ......... .... . NorthAnd er, Mass. Fee.. 1W .. . ......... Lic. No ...... ......... .. .... .. ... .......................... ELECTRICAL INSPECTOR Check # C9 16;4�L XZ Li�icTi; 40 5221 THE COMMOATHEALTHOF DEPARMENTOFPUBI BOAROOFFMEPREVEMOM APPLICATTONFOR PERMI' ALL WORK TO BE PERFORMED IN ACCORDANCE W. (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned Location (Street 2 Owner or Tenant (SETTS Office Use only Permit No. 5270 J2.V0 Occupancy & Fees Checked IRMELECTIZICAL WORK ELECTRICAL CODE, 527 CMR 12:00 Date D <` To the Inspector of Wires: Owner's Address ,q40v,--- Is this permit in conjunction with a building permit: Yes M No F-1 (Check Appropriate Box) Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Utility Authorization No. Overhead L J. Underground L—J No. of Meters Overhead r7 Underground M No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total 1 KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round round No. of Receptiile Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW Np. of Sounding Devices No.of•Self Contained Det@btion/Sounding Devices No. of Dryers Heating Devices KW LocalMunicipal Other t Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP t OTHER- h>ssu mce-Cmwge. Pmantwdr, tegxmimisofMassachusetts ColualLam [have aamentliabffitykormxPbhcyiwkxbnaComplei OperafionsCoNeworits YES NO [hamsuftrmmdvandproofofsarretothe Offim YES Fyoubawdrd<ocIYES,pleas fixhcatethetypeofcovaageby llgthe apprau& box rNSURANCEE BOND � (P1easeSpaafy) Expirafm Date Estimated Value of ledn al Wbik $ No&toStart /% thTec imDateRaVes�1 Rmgh Final ana �1pFs 7RMNAME of vc� !7ate, e L IiofseNo. icetlsee Signahue LiNo �l �J BusirmTelNo. Qj?�— VC20- 70 .-7- A" fsb U�'S/ ��f / % 1 Alt Tel. No. ���__� g" 3-P 3 )WNER'S INSURANCE WAIVER; I am aware that the license does nothavte the ins mncc coverage orits sutstuttial equivalent as tegtmed by Massachusetts Gerte Laws -id that my sig mw on this pemrit application waives this wgmeny-nt ?lease check one) Owner ® Agent Telephone No. PERMIT FEE $ tgna ure oT Mwner or Agent Name Name: Location: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston; Mass. 02111 Workers' Compensation insurance Affidavit Please Print City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address i City: Phone #: +� Insurance. Co. Policy # Company name: Address Ci r:Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 i and/or one years' imprisonment -as well_as_civil.penaltiesin-the form nf-a_STOP WORK_ORDER.and_a fine_of.($1D0.DD)_a dayagainst..me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. ! do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature. Print name Phon.e.# Official use only do not write in this area to be completed by city or town official City or Town Permit/Licensing � Building Dept ❑Check if immediate response is required [] Licensing Board ❑ Selectman's Office Contact persona Phone #. El Health Department Ei Other