HomeMy WebLinkAboutMiscellaneous - 32 BOSTON HILL ROAD 4/30/2018 (2) 32 BOSTON HILL ROAD
210/107.6-0071-0000.0
1
Date... ..��?......e .`,f.......
�•ORTN
°`t"`°:•�"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
3a t • ,
Y ,SSACNUSEt (///�
This certifies that ..... �-� :.
.....................:............_ ................................
has permission to perform ......... .,... - ................................................
wiring in the building of..a .:1' ... - ................................................
.:t ............ .,....................... .. ....4P/................. ,North Andover,Mass.
Fee..` ?............ Lic.N . ...� .........:. 0a.. . r........................
�1 / -,ELECTRICAL INSPECTOR
Check # 0�/�
5 '179
ThECOA ONHEALTHOI+'A/AS,AC'HU,SE+�,S Office Use only
DEPARTARMOFPIIBLICSAFETI' Permit No. Z
BOARD OFFIREPREVEIVTIONREG S527CMRI2.00
• Occupancy&Fees Checked �
APPUCATIONFOR PERMIT TO PE ORMELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSA USSTS ELECTRICAL CODE,527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �/� / 0V
Town of North Andover t To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical worl described below.
Location (Street&Number) 3�, �� �✓ ,
Owner or Tenant r)t-41-Ile 1016y, may.✓
Owner's Address
Is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box)
Purpose of Building 4 Utility Authorization No.
Existing Service Amps_ Volts OverheadUnderground No. of Meters
New Service Amps� Volts Overhead [= Underground r--J No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work %_1 h:,./C- 4-C,
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total
KVA
No.of Lighting Fixtures Swimming Pool Above Below Generators KVA
round 1A I Lround
No.of Receptacle 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 N9,of Sounding Devices
No':of Self Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal Othe
Connections
No.of Watee Heaters KW No.of No.of
t Signs Bailasis
No.Hydro Massage Tubs No.of Motors Total HP
)THER
stM10-3Coveiage.RusuanttDdrmgirit ofMaSSWk tlsCxl�Laws
taut;aamentliaAtyh> r&=Pohgy rhxlingComplete CoverageoritsmbstpiMequi,al YES NO
iawsubmittedvalidptoofcfsatwtothe0ffiM YES Y)culmwdrdp-dYES,pleaseiudi&drtypeofcovaage by
!edarrg the box 1�1
fSURANCEBOND OTHER ftn--
ExpitationDate
'�pp //yy E dValueofEbchicalWodc$
odc to Start tJ/��"`l/y4 a) htspection DateRegtested Rough Fatal
;ted UrK1C Rrlalties ofpjtuy
ZIVINAME ll �ZG% Licens �JF,7
eNo. q,..
oq
IicenseNo �7p�
Business Tel No.
clretc - Alt Tel No.
VNER'S INSURANCE WAIVER;lam aware that the Lieffm does nothave the insurance mveiaF orils sub aural equivalent as mquired byNLw-achusez Gernal Laws
.that my signahue on this permit application waives this mquamn t
ease check one) Owner ® Agent ® �-
Telephone No. PERMIT FEE$
tgnature ot Uwner or gen
a The Commonwealth of Massachusetts -
m r
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
°l�,M Sye Workers'Compensation insurance Afdavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
F-1 . I am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers'compensation for my employees working on this job.
Company name:
Address
City: Phone#: /
Insurance.Co. Policy#
Company name:
Address
City: Phone#:
Insurance Co. Policv# f
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 j
and/or one years'imprisonment-as_wellas_civil..penaftiesin.the form nfa..STOP WORK.0RDER.,an.d.a.fine-of-(.$1A0.00)_aldayagainstme. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone.#
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 I] Licensing Board
F-1 Selectman's Office
Contact person: Phone#. Health Department
Other