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Home My WebLink AboutMiscellaneous - 357 MASSACHUSETTS AVENUE 4/30/2018^9801b Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........5.7. 77.w.41..fto57 ...... . .............. has permission to perform ........4x�..e ........ wiring in the building of ............ .......................................... at .....33.7.....".- a- ....../61 North Andover, Mass. Fee.3�Lic.No. 1.7.11.7744, ......... Check #2 1351 on`d° �. p rn O m ��'� o' o m.ac'"oco P.y p�w� b p � oa. o a., r P ti op wP3 a ED ay p o o w ip� w ry Y'il jy' � rF � CD i 1 G P. tCt�, co r rt va O. O ��j hJ w CD 1 `� ° 15O 0 n p c�tiD p 4 pG'. Opo' , �• G' tph rt " R� R. 0 tl ° 0000 cad p w ti cao w p• 0 0 p rt O �O-y b v, O c 0 '��.� o f'h V o a rn n aq a CD ~ 'Cl CD w O b N o o w o4&wmp rcC, CSD 10 w w P, oar o a� 5 ��j co p p n�0i rypry�� n CD O .� NO 5 0 CD CS[ D O W w w n O [D P. R. O Gn � b �+ rt C'7 X Oq C pq cD a cD p• C: G p A. 10 CD �pcop'�C �•�o � o� rn �rn°oo o. 'Uq� pwwa �td� CDOQ Po° M N p � p �• w MKo N rnC, rn�o`n w co 00 b �• � � . y p. SU 'd O .�°. C� `° rt�bo�a��w ti o C1 {� CO) A.- y N N N w 0 CD � a M. _4 i " Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �54:5- 0 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z. • %-'/ 4 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersign giveoticegf his or her intentio�o perform the electrical work described below. Location (Street & Number) M �S V e Owner or Tenant UST) N e. CL. Q Telephone No. •11436 Owner's Address 5 09'4"e Is this permit in conjunction with a building permit? Yes ❑ Nqkt (Check Appropriate Box) Purpose of Building Existing Service _1W Amps I b / 2y0 Volts New Service 100 Amps 140 / 140 Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters viiisTON !. 146 L Completion of the following table may be waived by 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 ❑In- E:] rnd. grnd. o. of Emergency Lighting Battery Units No, of Receptacle Outlets No. of Oil Burners FIRE ALARMS 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 Heat Pump J.Number Ton_ s J.KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers HeatingAppliances KW pp Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: r. Attach additional detail if desired, or as required by the Inspector of Wires. • Estimated Value of E ectrical Work: 5 (When required by municipal policy.) Work to Start: 17 -PJ 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 suchcov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE6 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of rjury, that the information on this application is true and complete. FIRM NAME: : , ; I �•. E cat a 1 ( 4L— = C LIC. NO.: ' ?q72 A Licensee: � ArJ1y4 jam,• Signature LIC. NO.: Q C (If applicable, enter "ems t" 'n the lice nujer line.) `w �� Bus. Tel. No.. • 1 Address: I �� C_ -ITh%- .P'el� Alt. Tel. No.. L� *Per M.G.L c. 147, s. 57-61, security work requires Department of Public 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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): l �%, % ]li �; �•,� CTtI� q(_ _ iU Address: ' 10. City/State/Zip: M E16J 60, M A 1Ze.4 Mqy Phone #: %t�' BZ • .7 3 Sr Are you an employer? Check the appropriate box: I ,N�ram a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole have hired the sub -contractors listed proprietor or partner- 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. ❑ We are a corporation and its required.] 3. [:11 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.] t employees- [No workers' comp, insnrance required,] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other rr--�••••• •••••• •••_•.••=.o ir..:, r. a cuua� a: ll 1. ME [L'e SCCUCL_ Gmow shoI! mg their work—ms W' mp—c-sation. policy inS rrm-_tlon. # Hemeov m� uho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractor; and their workms' comp, policy information. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: tel' e S _7_ (V5U A#j(6 420 Policy # or Self -ins. Lie. #: W C - 3 q 11 (n q S Expiration Date: 66 /0112-011 Job Site Address: _ J 5 S S �V E City/State/Zip: N. AM ooys MA di i4 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 Iead 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 u the pains and penalties of perjury that the information provided above is true and correct Sienature: Date Z ' d 9�Phone #: 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 Contact Person: Phone #: of ItER11IT NO. I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP NO. LOT NO. 12 RECORD OF OWNERSHIP iDATE BOOK PAGE ZONE SUB DIV. T NO. I F — LOCATIONPURPOSE OF BUILDING s OWNER'S NAME NO. OF STORIES SIZE Q OWNER'S ADDRESS v v I BASEMENT OR SLAB ARCHITECT'S NAME on SIZE OF FLOOR TIMBERS ST 2ND 3RD I SPAN BUILDER'S NAME ' DISTANCE TO NEAREST BUILDING IV ._-- DIMENSIONS OF SILLS DISTANCE FROM STREET "' POSTS DISTANCE FROM LOT LINES - SIDES /a REAR �d GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE F ED AND APPROVED BY BUILDING INSPECTOR DATE FILED i C SIGNATURE OF OWNER WAUTHORIZED AGENT PERMIT GRANTED r 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST /' -2 /J� EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM .tem PERMIT NO./3o� 4 APPROVED BY C BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN X/ BUILDING INSPECTOR Y I 0110:)3a VNiaiins