HomeMy WebLinkAboutMiscellaneous - 350 ANDOVER STREET 4/30/2018_N
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4- C
North Andover Board of Assessors
MON
T.
roperty Record Card
Location: 350 ANDOVER STREET
Owner Name: KIRK, PETER R
LAURI PAPPAS-KIRK
Owner Address: 350 ANDOVER STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 0.72 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2002 sqft
ASSESSMENTS
a] Value:
ilding Value:
id Value:
rket Land Value:
apter Land Value:
CURRENT YEAR
346,300
158,700
187,600
187,600
PREVIOUS YEAR
339,000
145,600
http://csc-ma.us/PROPAPP/display.do?linkld=2253334&town=NandoverPubAcc 3/26/2013
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Date ..... L1�...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRIN
This certifies that ..T -A •''.4 .... -5./. .......
�1..................................................
has permission to perform .........i�,...."
wiringin the building of ........................................................................................
at ...3-, -w..... "J tip ....................... ............,,:.... , North Andover, Mass.
Fee ...... �b..... Lic. No..2Z�j...............��f./`ALINSPE&OR .�
IC ..................
hLECTR
Check # "Tr
Y Z--3
1 � : 7.,'
C.ommonwea[th o�a�acht�e Official Use Only
16 c
Permit No.
al.JeParfnzent o��ire �ervice�
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 PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: ///fixh f}/VDOyer To the Inspector of Wire—'s:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street A
Owner or Tenant
Owner's Address
Is this permit in ca
Purpose of Building e Gid X6to Utility Authorization No.
Existing Service /U u Amps 120 / a YO Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Overhead Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
Location and
/JNature of Proposed Electrical Work: ;?j,4g10 o?Y(/0� T POG1 ,-1 & d& -,q&_
INi/P GARAG E A,` DlP//PI T, Sl,�i7`��J 'A ZiGh rs
T Completion of the following table may be waived by the Inspector of Wires.
M
No. of Recessed Luminaires
No. of Cell: Susp. (Paddle) Fans
r o ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above ❑ n- ❑
Swimming Pool d. d.
o. o Emergency Lighting
Baftery Units
No. of Receptacle Outlets Q
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
an
o—.-5eteng D
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat m
TotalP
umber
............_...._......._
Tons
..........................................._._..
o. o elf -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑umcipa El other
Connection
No. of Dryers
Heating Appliances KW
Securitio oy
f Devices or Equivalent
No. of Water,
o. o o. o
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Equivalent No. of Devices or E uivalent
pp
OTHER: Pp1 C/ t l ,�%_t `0 a X/Y%/. / Q,fP &ez 30 &w w11V B nR�P11 I
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Ch CII&Inspections to be requested in accordance with MEC Rule 10, and upon completion.
" INSURANCE C VE : 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 cove a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: /94/'6/V 7-. ff, ..fe-41LIeC f/( AW LIC. NO.: I�RG
oG
Licensee:Q / Q J(% 'j sl , f j'Aoy Signature &a4rf eljyt LIC. NO.: e,� 6 7a q
(Ifapplicable, enter " mpt" in the license number line) Bus. Tel. No.: 40a us"/ 11436
Address:6�,1r AUf �P �y fLIA, a i ��y Alt. Tel. No.:.��t�78 ZSs� 9
*Per M.G.L. c. 147, s. 57-61, security work requires De6artment 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) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
I
I.
t
I
I.
.The Commonwealth ofMassachasetts , -
Department of lndgs€rigl.Accidiinis
Office of.Invesfgations
644 Washington Street
Boston, AM 02111
www.mass govIdia
Wo rkexs' Compensation bsurance Affidavit: EuiYdersiContractor$/Electricians/Pliio pM.
AMUcant information Please Print LeONY
Name (Busia0ss/Orgm zation&dMdual): 4041 7-`x.1 T T.
Address:
City/Stat,/ftp: /ylof7�t/ /Zl.� 1��� Phone:
Are you an. employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with.
4- ❑ I am a general contractor and I
6. ❑ New cOnstraction
employees (full andlor part-time).*
� or
have r&edthe sub -contractors
listed on the attached sheet:
7• [] Remodeling
2. I am a sole proprietor partner
ship and haveno.employees
These sub-contxactorshave
S. [(Demolition
worldng forme in any capacity.
workers' comp. insurance.
9, [] Building addition
[Nb workers, comp. insurance
5. ❑ We are a corporation. and its
officers have exercised.their
10 Electrical repairs or additions
required.]
3-E] I am a homeowner doing all work
right of exemption per MGL
11..[] Plumbingxepairs ax additions
myself [Eo workers' comp.
c. 152, §1(4), andwehaveno
12,Q Roofrepairs
insurancerequired.] ?
employees. [No workers'
13.[] Other
comp. insurance required.]
,!Any applicautthat checks boxfil mustalso f l outthe section below showingPheir workers' compensation policy information.
t' Homeowners who submit his affidavitiadicatl.ngthey2'redoinganworltand then hireoutside contractors must submit anew affidavit indicatingsuch.
tcontcactors that checktbis box must attached pa additional sheet showingthe name of the sub. -contractors andtheir workers' comp. policy information.
IM an employer that fsproviding Workers' comPeras'aiion insuFance fog fny ernproyees Be%sv is thepolicy anrirob site
infa rmallon.
Insurance CompanyName,%
Policy #i or Se1r ins. LIG. M' Expiration Date:
Tob Site Address, City/Statelzip:
Attach a copy of tile, workers' coxapensation-policy tleclaration page (showing the policy number and expiraiioa crate).
Failure, to secure coverage as xequiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a
fere 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 tine
ofup to $250.00 a day against the violator. Be advised that a copy ofthis statem.entmay be, forwarded to the Office of•
f vestigations of the DIA for insurance coverage verification.
-Z' do 11areby cert D under the pains and penalties of pet triat t/ -, in forrnrztion provicTec� above is true and eo�reet.
Phone g:
official use only, dlo not write in this area, to be compieted by city or town official.
City or Town:
PermitlLicense
Issuing.Auithority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Numbing Inspector
6. Other
Information and Insirnctions
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 k the service of another under any confract of hire,•
express or implied, oral or written!,
An eWfoyer' is defined as "an individual, partnership, association, corporation or other legal entity, or any two ox more
of the Foregoing engaged in a joint enterprise, and includingthe legal repxesentatives of a: deceased employer,, or the
receiver ox irtisfee o an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant of the,
dwelling house of another who employs persons to do maintenance, construction of repair work on such dwelling house
or on the grounds orbading appurtenant thereto shall not because of such employment be deemed to be an employe."
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, MGI, chapter 152, §25C(7) states'Waitherthe commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublie work until acceptable evidence of compliance with the insurance
requirements of this chapter have beenpros onto dta the contracting authority."
Applicants '
Please X11 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
no odsary, supply sub -contractors) name(s), address(es) andphonenumber(s) along with their eextificafe(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than, the
members orparinexs, arenotrequiredto canyworkers' compensation inmrance. If an LLC orLLP does have
employees,apolicyisregtured. Be advised thatibisaffidavit maybe submitted tothe Department of Industrial
Accidents for conhrination of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
b e retnmed to the city or town that the application for the permrit or license is being xeguested, no E the De rariment of
Industrial Accidents. Sb ouldyou have any questions regarding the law or if you are required to obtain a Workers'
compensationpolloy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. I
City or Town Officials
Please be suxe that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom
of the affidavit fox you to frll out in the event the Office of htvestigations has to contact you regarding the applicant.
Please be -sure to fill in the permit/Rcense number whichwill be used as a reference number. In addition, an applicant
that must submit multiple p ermit/11cense applications in any given year, need only submit one affidavit indicating current
policy iMformation (ifnecessary) and under "Job Site Address" the applicant shouldwrite "all locations in (city or
towzt): ' .A. copy oFthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as fth
prooat a valid affidavit -is' on rile fox future p ermits or licenses, Anew affidavit mmust be filled out each
year. Where ahome owner orcitizenis obtaining a license oxpermitnot related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affYdavit.
The Off lea bf Investigations would like to thank you in advance fox your• cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone ahA fax number.
`S'het Ca: 4 a t�Z o saachv._. ell
D -Ta tell QfkdU*!aX Accidenta
Off co o: hT VQSRgAvalt,%
Boston, 02111
W. 4 617-7-2-2-4. 00 at 406 Qx 1-877�.AS,�g
Revised 5-26-05 `ay, 617"727'7749
. �•�a�,g9v'�c3�a
W
Location
No. 3 Date
�oRT� TOWN OF NORTH ANDOVER
F 9
" Certificate of Occupancy $
�'s''•° • E<� Building/Frame Permit Fee $
s�CHus
Foundation Permit Fee $
Y Other Permit Fee $ -
TOTAL $ a
Check #
2---t,
17360 �/
l/ Building Inspecti�T
% Z — 0-/
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
TI;Is:Sec6to�<for(?fi">ic lUse"Oil
BUILDING PERMIT NUMBER: �&
DATE ISSUED: _ ?
SIGNATURE:
Buildin �Commissioner/I for of Buildings Date
�r� tivt� r-J11G llvrumiviA11V1`1
1.1 Property .Address:
1.2 Assessors Map and Parcel Number:
c2�� �yd 1p
A \,tel Map Number Parcel Number
1.3 Zoning Information: 14 Property Dimensions:
i rias ua c tri
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Reqwred Provided Required Provided
1.7 Water Suppty M.G.L.C.40. 5 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private 0 1
Zone . Outside Flood Zone 0 Municipal 0 On Site Disposal System
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Pent) Address for Service
Signarure Telephone
2.2 Owner of Record
Name Print
l Siv lure -- -- - -
;ION 3 - CONSTRUCTION SERVICES
=/ j-,).ensed Construction Supervisor:
z
Licensed Construction Supervisor:
Address
Signature Telephone
1.2 Registered Home Improvement Contractor
,ompany Name
Adress
ignature Telephone
Address for Service:
Not Applicable 0
License Number
Expiration Date
Not Applicable ❑
Registration Number
Expiration Date
SECTION 4 - WORKERS COMPENSATION (NL 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 ....:..0 No ....... ❑
SECTION 5 Desrrintinn of Prnnnsed Wnrlr (rhe iz an wnnlicnhia I
New Construction ❑
Existing Building 0
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg, ❑
Demolition ❑
OtherSpecify U
Brief Description of Proposed Work:
9 lid Z V'O V\-
lSECTION
SECTION6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost Dollar to be
Completed by permit applicant
'�._'
1. Building
^ O�
V�
(a) Building Permit Fee
Multiplier
2 Electrical
��(b)
5 W •
Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (al X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total (1+2+3+4+5)
0,0- UV
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 OWNEK/AUTHOKIGED AGEN1' DECLARATION
F i l
I, \ (`-_ \C1 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 km
Print Na e `
S i g n a t f er Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 3KD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIIv>ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CI-IIIviNEY
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 approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT PHONE 6:� 7^�
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION
LOT NUMBER
STREET ���Vtd ue
STREET NUMBER "3S-0
OFFICIAL USE ONLY
RECO NDATIONS OF TOWN AGENTS
...... '................■ ..................................
..u.........
DATE APPROVED a /
CONSERVATION ADM NISTRATOR
DATE REJECTED
COND/IENTS
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INSPECTOR - BEALTH
DATE REJECTED
DATE APPROVED
SEPTIC INSPECTOR - HEALTH
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER / WATER CONNECTIONS
Ib�.�uf VA.M`i'i�l�y
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR
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_a--
I JOHN S. LAURETANI
A PROFESSIONAL LAND SURVEYOR
DO HEREBY CERTIFY THAT THI
ABOVE MORTGAGE INSPECTIOP
PLAN WAS PREPARED FOR
CONNECTION WITH ANEW MORTGAGE
AND IS NOT INTENDED OR REPRE-
SENTED TO BE A LAND OR PROPERTY
LINE SURVEY. NO CORNERS WERE
SET. IT CANNOT BE USED FOR ES-
TABLISHING FENCE, HEDGE OR
BUILDING LINES. THE LAND AS SHOWN
HEREON IS BASED ON CLIENT FUR-
NISHED INFORMATION AND MAY BE
SUBJECT TO FURTHER OUT -SALES,
TAKINGS, EASEMENTS AND RIGHTSOF
WAY, N_Q RESPONSIBILITY IS EX-
TENDED HEREIN TO THE LANDOWNER
OR OCCUPANT, IT IS NOT INTENDED
TO BE RECORDED
DATE
CLIENT_
CLIENT REF.#
JO It I1C
Scale: I - 140'
AMERICAN SURVEYING COMPANY
77 Rumford Avenue, Waltham, MA 02154 (617) 893.6477
Mortaaae Inwection Plan
N\/F
G E_OQC'f-..
THE LOCATION OF THE ORIGINAL RECORDED AT COUNTY REGISTRY OF DEEDS
DWELLING SHOWN HEREON EITHER BOOK -5-6 PAGE 10 L L.C. Cert. #
WAS IN COMPLIANCE WITH THE LOCAL PLAN REFERENCE: n%- r 1Q. 5099 OF 1964
APPLICABLE ZONING BYLAWS IN EF- DRAWN PER TOWN OF ASSESSOR'S
FECT WHEN CONSTRUCTED WITH RE- MAP # PARCEL # DATED
SPECT TO HORIZONTAL DIMENSIONAL ADDRESS: 150 4N01 -c_ Sv:F-T
REQUIREMENTS ONLY), OR IS EXEMPT NOCL] a A. t00VK "_ , MA
FROM VIOLATION ENFORCEMENT AC- BORROWER:
TION UNDER MASS, G.L. TITLE VII, CHAP. 41
40A, SEC. 7, UNLESS OTHERWISE SUBJECT DWELLING LIES IN FLOOD ZONE
NOTED OR SHOWN HEREON. A CON- AS SHOWN ON NATIONAL FLOOD INSU ANCE PROPjiAM FLOOD
FIRMATORY INSTRUMENT SURVEY INSURANCE RATE MAP DATED___ 2%/n� IS` Int I3
IS ADVISED WHEN STRUCTURES ARE COMMUNITY _ PANEL # : X09 00/013
SHOWN TO BE V OR LESS FROM FIELDED DRAFTED CHECKED
PROPERTY OR REQUIRED ZONING 8Y MYH 'L
SETBACK LINES.
DATE In_�.S-9S i1 -ZS -4f. F.B. PGF
TO/T0'd MaNnw m21HW Ol NUDId3WU WONA 80:VT S6GT-8E-A0N
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542. Fax
Please print.
DATE -5— O
JOB LOCATION
Number
"HOMEOWNER
Name
PRESENT MAILING ADDRESS_
t�
City Town
HOMEOWNER LICENSE EXEMPTION
_11douf K_
Street Address
Home Phone
vi° e'—
State
Map / lot
f -l -x-77 79 7F
j xz7e -- Work Phone
•
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than onehome in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that
Building Department minimum inspection pi
comply with said procedures and requireme
HOMEOWNER'S SIGNATUR
APPROVAL OF BUILDING OFFIC
tands the Town of No. Andover
requiremegts and that he/she will
Zip Code
QL4RYi•t-�
QTtD 4i�fV!
- Town of North Andover
Building Department
27 Charles Streeto
North Andover MA. 01845
�M
�SSAra»4'o�6�
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542. Fax
Please print.
DATE -5— O
JOB LOCATION
Number
"HOMEOWNER
Name
PRESENT MAILING ADDRESS_
t�
City Town
HOMEOWNER LICENSE EXEMPTION
_11douf K_
Street Address
Home Phone
vi° e'—
State
Map / lot
f -l -x-77 79 7F
j xz7e -- Work Phone
•
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than onehome in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that
Building Department minimum inspection pi
comply with said procedures and requireme
HOMEOWNER'S SIGNATUR
APPROVAL OF BUILDING OFFIC
tands the Town of No. Andover
requiremegts and that he/she will
Zip Code
Date..� .........
TOWN OF NORTH ANDOVER 4
PERMIT FOR WIRING
This certifies that ... 0.. f!? .......7 /.........1.7t �K� i .......................
hadpermission to perform ..... . ................................
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L
wiring in the building of .......................................
at ............ ..... .
C......................eNorth Andove
S.
Fee .... 4/-f .......... Lic. No. 0 ..... ..........
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Check #
5295
THECOADfOAWEALTHOFh1ASS4CHUSETTS Office Use only 91
DEPARTNlE'NTOFPUBLICSAFETY Permit No. O�/✓
BOARD OFFMPREVEMONREGULANONS527 CAR12.-GV
Occupancy &Fees Checked
APPUCATIONFOR PERMIT TO PERFORMELE=CAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date,
T�%Zie
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) -5so 14AI)OV-616 s fi
Owner or Tenant f
Owner's Address N o o V of 7 a 7
Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead Underground No. of Meters _--
New Service: Amps / Volts Overhead Underground r__J No. of Meters
Number oV Feeders and Ampacity
Location and Nature of Proposed Electrical Work 7=7/27 6 f A%0 ve 777,bgAl a 757
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool
Above
Below
Generators
KVA
round
round
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
r
Tons
No. of Disposals
No. of Heat
Total
Total
No. of Detection and
Pumps
Tons
KW
Initiating Devices
No. of Dishws4hers
Space Area Heating
KW
Ng.,of Sounding Devices
N4'` bf Self Contained
Detection/Sounding Devices
No. of Dryers
Heating Devices
KW
Local Municipal
Other
Connections
No. of Water Heaters KW
No. of
No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
THER-
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ave aamerALmbihtylmanceFbhcynrbdngConip!Et2yahonsGDveraWarZsubstaritialegtuvalerlt YES F71 NO
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TIER'S INSURANCE WA1VEP, I am awatethattheLiomsadoesnotha,
that my signature on this pemut application waives this legtiileniEi t
;ase check one) Owner ® Agent
'Signature oT Owner or 7genf
LiomseNo. 7a,!
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BumaessTel No. f -s
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theirisurancemveiaocoritssubstarllialegrmleivasoWtedbyMassachusenGeneiWLam )
Telephone No. PERMIT FEE $J .
Name
Name:
Location:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02119
Workers' Compensation insurance Affidavit
Please Print
City Phone #
I am a homeowner performing all work myself.
0 n
I am a sole proprietor and have no one working in any capacity
aI am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance. Co. Policv #
r
�l
Company name:
Address ;
City: 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
and/or one years' imprisonment -as _well_as_civil penaltiesin.Sheform nf-a_STOP WORKORDER.,and_a.fine.of_($1.00..00)-a day-against..me.
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 infonnation 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/Licensino
Li Building Dept
Licensing Board
Selectman's Office
Health Department
Other
❑Check if immediate response is required
Contact person: