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HomeMy WebLinkAboutMiscellaneous - 36 MAPLE AVENUE 4/30/2018Date ...... 1... .. -7..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING . This certifies that ... .........-...:...`:'..`.....C'...f............................................................................. C. has permission to perform ............. ?:5;:..,,........ . ?.. ; ........................................................ wiring in the building of........... JPS. ..................................................... 11a 0� ,/ at ... �..... �.....:�..................f?t/L........................................ > North Andover, Mass. Fee....L. ............. Lic: No..:....-....:_�u•- / ............!.C�.................. ELECTRICAL INSPECTOR Check # 7 7 / 12918 -/ 4 t C,cca''►ntsaorirusali�z o� It'laa�aaituae� = e1.Jopar�tn�nar# o��ira �aruico9 i BOARD OF FIRE PREVENTION REGULATIONS Official use Only Permit No. , Occupancy and Pee Checked tev. 1107] (leave blanks APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MGC), 527 CMR 12;00 (PLEASE PRINT IN INK OR TYPE ALL IA7I;WO: RAMTION) Date: tJ 1 f C City or Town of: ' bra-kx,"yu , To the Inspector of YVires: By this application the undersigned gives notice of his or Fier intention to perform the electrical work described below. Location (Street & Number) 3k 04RIt 'J"u- Owner or Tenant Telephone No. q $ • Q ( 4 Owner's Address Is this permit in conjunction pith a building permit? Yes I& No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead[F] Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system [ 30 j panels rated f ')'g ] kW (@ STC Grid Tied. In conjunction with a Buildina Permit Co,vivietion of the folloivinz table war be iraived by the Inspector of Mies. No. of Recessed Luminaires No. of Ceil,-Susp• (Paddle) Fans No. of Total sfornxers KVA No. of Luminaire Outlets -Tran No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Elltd.L1o- rnd. rnd. o mergency rg ing Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners - o. o election and Initiating Devices No. of Ranges No. of Air Cond. 'Iota Tons No. Alerting Devices g o. o No. of Waste Disposers lieat ump Totals: NumberFons K o. of elt ontained Detection/Alcrting Devices No. of Dishwashers Space/Area IIeating KW Local ❑ Cunncill an ❑ Other cti No. of Dryers Heating Appliances KW SecuritySystems:* No, of Devices or uivalent No. of afar K1V Heaters No. of i o. o S' ns Ballasts Data Wiring: No. of Devices or Equivalent No. hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail tfdeslr ed, or as required by the Inspector of 1.11res. Estimated Value of Electrical Work: o O (When required by municipal policy.) Work to Start: ASAP 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: INSURANCES BOND ❑ OTHER ❑ (Specify:) I certify, under the pants tntd penalties ofperjutyp, that the ittfortnation on this tepplication is true and contplete. FIRM NAME: SOLARCITY CORPORATION LIC, NO.:1136MR Licensee: MATTHEW T. MARKHAM Signature LIC. NO.:1136MR (If applicable, enter "exentpr" in the license mtnnber line)Bus. Tet, No.:774-258.8180 Address: 24 ST MARTIN DRIVE (BUILDING 2- UNIT 11) MARLBOROUGH, MA 01752 Alt. TCI. No.: 774.25&8505 *Per M.G.L. c, 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAI VER: 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) [3 owner []owner's er's a ent. Own nt Signature htre Telephone Na. PERMIT FEE: $`� . ~ ✓�'.d,' V/�D7ir�JttC�'lt,Il.M,tt'l tgt o �, AwwarliatwA Office aC C011Sumc;r Al FaiK and Business Regulation 10 Park Plaza - Shite 5170 Boston, Massachusetts 021 16 Home Improvement Contractor Registration SOLAR CITY CORPORATION MATT MARKHAM 3055 CLEARVIFW WAY SAN MATEO, CA 94402 .4r, b to, Registration: 168572 Type: Supplement Card Expiration: 3!8!2017 r y Update Address and return card. Mark reason for change. Address Renewal Employment Lust Gard A . 14.1 11 Mw. I/ /'r#... X"AwK Office of"Consumer A ftalrs A Business Rtgaintion 1 •icense ur registration valid for indit idttl use only HOME IMPROVEMENT CONTRACTOR before the eapirmion date. if found return to: Office of Consumer Affairs and Business Regulation RogIstration: 16A572 Typo: 10 Part: Pla7m - Suite 5170 I:ximation: 3:',L2017 Supplement Catd Roston. \1.102116 SOLAR C11 MATT MARI'l W.1 24 57 MARTIN 51 sii_L T 131-17 7.UNi MWBOROUGH, MA 01752 I�nJeUndo "~ rsecretari ivoi valid without signature 1 ME Xw= E L E CTR I C I Ali S t ISSUES THE FOLL.OwING LICENSE AS A►\. -� REGISTERED MASTER ELECTRICIAN ��� 50I.ARC I TY CORNORA'I ION HATTHLW T MARKHAM 24 SAINT MARTIN OR SLOG 2 UNIT II 'Z AARLBOROUGH MA 017 - t1iYi} r �t w Update Address and return card. Mark reason for change. Address Renewal Employment Lust Gard A . 14.1 11 Mw. I/ /'r#... X"AwK Office of"Consumer A ftalrs A Business Rtgaintion 1 •icense ur registration valid for indit idttl use only HOME IMPROVEMENT CONTRACTOR before the eapirmion date. if found return to: Office of Consumer Affairs and Business Regulation RogIstration: 16A572 Typo: 10 Part: Pla7m - Suite 5170 I:ximation: 3:',L2017 Supplement Catd Roston. \1.102116 SOLAR C11 MATT MARI'l W.1 24 57 MARTIN 51 sii_L T 131-17 7.UNi MWBOROUGH, MA 01752 I�nJeUndo "~ rsecretari ivoi valid without signature 1 ME Xw= E L E CTR I C I Ali S t ISSUES THE FOLL.OwING LICENSE AS A►\. -� REGISTERED MASTER ELECTRICIAN ��� 50I.ARC I TY CORNORA'I ION HATTHLW T MARKHAM 24 SAINT MARTIN OR SLOG 2 UNIT II 'Z AARLBOROUGH MA 017 - t1iYi} r �t w t The Commonwealth of Massadi usetts .Department o, f IndustrialAccidents Office of Invesdgations I Congress Street, Suite 100 Boston, MA 0,x.114-2017 NVWW.MffSS.golt%fta Workers' Compensation Insurance Affidavit: Builders/ContractordEiectricians/Plumkers Aypfignt In ormatian Please Print Le ibl Name (Husincsdorganization/individuaD: SolarCity Corp. Address: 3055 Clearview Way uttytwate/�i : San Mateo UA. U44UZ rt one v: 000-/ uo-L-tou Are you an employer? Check the appropriate box: Type of project (required): 1,� am a employer with 5,000 a r l' 4- D I airs a general contractor and I b. [Q New construction emplay+ras (ful) and/or part -titre).* 2. ❑ I am a sole proprietor or partner.- have birt d the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These subcontractors have 8. 0 Demolition working for the in any capacity. employees and have workers' 9. []Building addition [No workers' comp. insurance required.i camp. insuronce. 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I ant a liameowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions xnysolt [Nu workers' camp. Aelt of excavagn pet 1,140E 12.❑ Roof repairs insurance roquired,l t c. 152, § 1(4), and we have no employees. [No workers' 13�;-�,Cher Solar/PV L r f eomp. insurance required.] }Any applicant that checks box B I must also rdt out The section below showing their wottas, compensation poiioy information. I liotneawners who submit this affidavit indicating ibey are doing all work and then hire owsid,c contractors most salrmit anew afdavit ladiwing such. =Contractors that cheek this box must attached on additional sheat showing cite name of the sub.cornactora and state whether or not those entities havc employtms. If the sub•contraelors havc employees, they mast provide limir workers' comp policy number. Tarn an emploper-that is providing workers' compensation Insurance for my employees. Below is the polley andjob site iujorruatior:. Insurance Company Name: Zurich American Insurance Company Policy -M! or Self --ins. Lic. #: WC0182015-00 Expiration Date; 9/1/2016 .lob Site Address: 3 da K 6UDAL Ay ` City/State/zip: � � �) 01 er MAS Attach a copy of the workers' compensatitm policy declaration page (sh owing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal pertaltics of a line up to S 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 tip to $250.00•a day against the violator. Be advised that a copy of this statement nlay'be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certl'jy under the pafry and penaltles of perjury that the information provided above is true and earrert. Offklal use mly. Do nal write in this area, lobe completed by Illy or tower aj}'tclal. City or Town: Permit/t.lrense i, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector b. Other Contact Person: Phone #; ACVR,D® CERTIFICATE OF LIABILITY INSURANCE ' CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 0811712015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE= OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Wan ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT V019'. MARSH RISK & INSURANCE SERVICES .._... .... ....._.........---..._.. PHONk .._..................... ... "T FAX 345 CALIFORNIA STREET, SUITE 1300 .1411;No. ExU:......... __ .._ ... _.........................WP.Nr+4..................................... CALIFORNIA LICENSE NO. 0437153 EMAIL SANFRANCISCO, CA 94104 _APpR€;zS;.......................... ...................._.._..................... _...... T_........................_.. Attn: Shannon Sood 416-7438334 ....... .... INSURER;&] AFFORDING CQVERAOE.. ... . .. ................{ ... NAIC p 99&301STND-GAWUE-15.16 IINSURIER A; Zurich American Insurance Compalry 1.16535 INSURED INSURER s; NIA NIA SolarCity Corporation t .. ......... .... 3055 Clearvlew Way INSURER C: NIA NIA San Mateo, CA 94402 wsuRfR.DAmerican Zurich Insurance Company 140142 :PERSONAL INSURER E: 3,000,000 INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002713MOS REVISION NUMBERA THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLDD,AIMS- IH AitifiLSUBR — t'OLtCY EFF 'MVIDDIYYYYI. POL ICY EXP'! _. of Marsh Risk & Insurance Services LrR TYPE OF INSURANCE POLtCY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY jGLOO182016-00 00112015 0910112016 EACCH OCCURRENCE S H 3,000,000 r X I I 4Ai#ENTFEa.......... �._._......._...------ 3,000,040 CLAIMS -MADE I OCCUR i PREjjA18.E5 LEA pocurrencel ....*.5 ................. X SIR; $250,000 i j ME O EXP (Arty one person)..... ��. . _ 5,000 :PERSONAL &ADV INJURY S 3,000,000 GEN%AGGREGATE LIMIT APPLIES PER i GENERAL AGGREGATE $ 6,000,000 XPRO- POLICY I JECT i„..; LOC PRODUCTS - COMPIOP AGG : S 6,000,000 OTHER S A , AUTOMOBILE LIABILITY 'BAP0182017.00 `09!01120115 0910112016 COMBINED SINGLE LIMIT S 5,000,000 )( ANY AUTO BODILY INJURY (Per person) . S X :ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) ; $ I..... X X NON-ONMED HIRED AUTOS AUTOS PROPERTY DAMAGE : $ .; I.... COMPICOLL DED: S $5.000 UMBRELLA LIAB ''OCCUR EACH OCCURRENCE 'S EXCESS LIAB CLAIMS MADE` AGGREGATE S DED RETENTIONS S D 'VYORKERSCOMPENBATION 4VC4182014 aa(Aos) 0910112015 0910112016 X :PER ;DTH- ; AND EMPLOYERS' LIABILITY A YIN. WC0182015.00 MA .0910112015 09101/2016 .ANY PROPRIETOR/PARTNERIEXECUTIVE E i F..._...� STA..TUTE. ,......i �R ..... j... .. • E.L EAC H ACCIDENT ' S 1,000,000 :OFFICERIMEMBEREXCLUDEO7 N NIAI F_.....___ -.._..._ ..................j. .. (Mandatory In NH) NIC DEDUCTIBLE: $500,000 E.L DISEASE - EA EMPLOYEEi S _ ................ .. .. ......... 1,000,000 N yes. descnbo under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT I S 1,000,000 DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more space is required) Evidence of insurance. CERTIFICATE HOLDER CANCELLATION SolarCity Corporation 3055 Clearview Way SHOULD ANY OF THE ABOVE DESCRI13ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BS DELIVERED IN San Mateo, CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo ©1988-2014 ACORD CORPORATION. All rights reserved. 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E- w 0 Ei �l o .o x c' - ti : '. �-58 E: E P: t o o: o. u: t: t E g: o 2 W o:.s 72 � L� � .: Z u:u <'m Q:0 o c:._ a: �.:E u z z: W: 0: wl _: ao -0 ;n f: E E 4D ', 4" % M Uj Z Lu rz LO ICID > Z 0 r — 0 c 0 :p o U U 00 nn U > o 0 0 'r- '0 2 t " W m o a u > V) —:3 c c cu v On 0 10 E O m Y E 76(U ro "Cl CL m S vi E V) ca 0 ao -0 Claim # 2459196 Advantage Claim Serv-ices Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health (t/ Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA 01845 Re: Insured: Doherty Condominiurgs Property address: 36 Maple Ave. North Andover, MA 01845 Policy #: 2459196 Loss of: 2013/06/10 File or Claim No. AD 9857 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. _Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_ Gen_ Laws, _Ch. _139_Sec. _3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. [�7RECEIVE®�� 06-19-13 Signature. and date JUN 26 2013 'OWN OF NORTH ANDOVER ` HEALTH DEPARTMPNT Claim # 2459196 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner ow✓ Inspector of Buildings Town Hall North Andover, MA 01845 Re: Insured: Doherty Condominiugs Property address: 36 Maple Ave. Board of Health or Board of Selectmen Town Hall North Andover, MA 01845 North Andover, MA 01845 Policy #: 2459196 Loss of: 2013/06/10 File or Claim No. AD 9857 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. _Gen._Laws,_Chapter_143,Section_6 to be applicable. If any notice under Gen—Laws,—Ch.-139—Sec.-3BMass _ is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 06-19-13 Signature. and date Location No. —Z Date a TOWN OF NORTH ANDOVER r� . 6 -pG ' a Certificate of Occupancy $ Building/Frame Permit Fee $ s�c►+us Foundation Permit Fee $ / Q ��:� -^6tt'tisY Permit Fee $ _ Sewer Connection Fee $ 6 Water Connection Fee $ TOTAL $ n, Building Inspector 0 a 9846 Div. Public Works ` U a W � i � v � \ IL O !z Y 00 4 O p� O A 7 m Y m W Z O W 3 uFi �q N W W O Q IL 1C O Oa Z I o + Ii C J CO O W CL oK Z .. VU w 1. 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(2c)c:>nrl 1.:301 Boston, P•9as:aacLisett.:s 0:.1063 CONTCcACTOR RE,9i.sJ_1-ijt,i11. 3204 ExpiT-ation 02/1.2/97 1-ypo ._ C-41: ]CVAT"E CORPORA1..10111 FAMILY POOLS — PATIOS INC WILLIAM C. GIANOPOULOS `92 S BROADWAY LAWRENCE MA 0184:3 L u Cj DEPARTMENT OF PUBLIC SAFETY ONE ASHBURTON PLACE, RM 1301 BOSTON M` '.,02108-1618 c r-1 A CONSTRUCTION SUPERVISOR L Number: Expires: CS 010330 07/19/1997 Restricted To: 00 WILLIAM C POULOS 92 S BROADWAY LAWRENCE, MA 01843 � ��e �omanuxu�P,a,�t o�,_/�✓iaaaaTl�,uaeC,J DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nuiberit Expires: Birthdate: CS°' 4; °.010330 0111911991 0111911960 Restricted To; 00 WILLIAM C POULOS 92 S BROADWAY LAWRENCE, MA 01843 - BirthdAte. PAID AUG 16'95 D.P.S. 07/19/3960 m -- = Detach bottom, fold sign on ' , back, and laminate license card. eep top for receipt and change 4of address notification. Restricted To: 00 00 - None lA - Masonry only 1G - 1 & 2 Family Homes Failure to possess a current edition of the Massachusetts State Buiilding Code is cause for revocation of this license. — rrl FT COti EXIST. S rn DECK W/ ST rn Xm Ci EXCLus T r- (A� � � �/J. UNIT A rn J6' m° S� ren II Z syys� + EXIST. OPEN WOOD DECK W/STAIRS EXCLUSIVE TO FO � Ln UNIT B _ V� + c COMMON TO O j ° &1 1 BOTH UNIT o v � q�04, Ta A & B rn BASEMENT, ENTRANCEWAY m x S��'p sS 6 K ADE ��cFA S Z �/Q EXIST. STOC FBF l rn _ ��ELECTRIC METERS F rn X z CF °� n r f EXIST. DIRT S; rn m mo p DRIVEWAY 0rn O 0 EXIST. B WALKWAY,. p — (DEED) NCZ sa 110+� TTZ F � /✓o ---- EDGE OF PAVEMENT �o � D PUBLIC) Y1 STREET (509 SECOND r , J o � • K � a ��iy. K� r ! �� a :.t'•'j S �. � Y e ET'J�� : � � 1 • , x e s � �..� � ; ;iib "r. . �€ $ 1 IVA Y �[ �y r J ..t y J W Z q CC ��e IYY -at d p a o ]g .•d .� b i� Sx+'J J JI '� i 3Y r' �; <i �•' "j 0 0 in Z O cn w _ w to U 1 x 0 Q N , a v c C O J _ a u � m oc o � 0 f- a > r J L -0 C. r✓ L >' N F c m n w e -i W a Z � = Q J W N• a °i �: � Q'0 A 3 .= 2-0 OL Q3Oa N Q J -Y n- o E y � oQ o 3 S v u t F 0 aD° �� U Q z J p w .. O ? 0 d O r v > c n o m c`i o ° G ° CL r CL ; n vi o >. Q4. c - o� c N u E cV- aw— I- a ` QL �iv c a, ; c �-0 > C: 0 0 _j JUcc0 J LLJ o. ej `o a N u. aON C N�NY Z-2� >_�° �� � - 'D m a E �� -o �� E o 00v ti -a J 3�z.� .� QO W oN L ? .00 o D N C —roV pQ_Q Q �p�E a m� �c of �_ o_u cv a�3 Op2Z QW Q L o a`, E E E c 010 o' (U i a, o V � N c•i v ui � � m W OL N , a v c C C' 1 I J _ a u � m oc o � 0 C ca L > r J L -0 C. r✓ L >' E F LL. C In Q O 1 � = Q E 3 D � T R i m > 0 E n � Q'0 c0 y U C' 1 I u 1 u u ,I VI S y O D m �I G II H •i C ca L > r J -E— C. r✓ L O O °i �, CLo 0 >A 1 .0 .c1 U � N O VI S (� / •O O IC J G C ca L > r J -E— C. r✓ L O O °i �, CLo 0 >A > in E 3 E = E > 0 E n - c0 y ' N N J z O Q ct a O m O z n O cc Iy w n O_ H D Q U io O IC J hy2 000 C 1htiU� C. uu•p � Hh� U S�$ a Q N io FORM U - VERIFICATION 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 local or state law, regulations or requirements. ****************Applicant fills out this section**************�*1*(�* APPLICANT: Ji�"t,( �.AAWX Phone ,&2Z_` LOCATION: Assessor's Map Number Subdivision Parcel Lots) Street ,�6 Ampl f '#or A St. Number :3 4 ************************Official Use Only************************ RECOPTPMATIO OO AGENTS: Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments Date Approved Date Rejected 14 Date Approved Food I ctor a Date Rejected Mama Date Approved Septic Inspector- eal h Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Li__�Ze�ce�ved by Building Inspector 1419% i Date y � • I'I Office use Only idle Lfommoniurdth of Ainsatffs Permit No. � U/ Occupancy & Fee Checked �E�IIIitIItElit Qf �1If11[t P c1l �. BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 0 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 2:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date M( or Town of NORTH ANnOVF.R To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address ~� Is this permit in conjunction with a building permit: Yes _ No L] (Check Appropriate Box) Purpose of Buildina ��� r< Utility Authorization No, r-- Existing Service Amps _J Volts Overhead i Undgrnd 1 New Service Amps Voits Overhead Uncgrno Number of Feeders and Amoacity Location and Nature of Pr000sed Electricai Work No. of Meters No. of Meters Totai No. of Lighting Outlets i No. of Hct _bs No. of Transformers KVA in - No. of Lighting Fixtures i Swimming Pcoi r.c e- erne. ! Generators KVA iI No. of Emergency Lighting No. of Oil Burners No. of Recectacie Cutlets 3artery Units No of Switch Outlets No. cat Gas 3urners I FIRE ALARMS No. of Zones Totat No. of Detection and No. of Ranges No. of Air Cone. tons Initiating Devices iNo. of Disposals No.of Heat Total iotasPur;as Tons KW No. of Sounding Devices iVo. of Seif Contained No. of Dishwashers SoaceiArea Heatir.a KW Detect:oniSounaing Devices ' — Municioai '—Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low I/citage No. of Water Heaters KW I Signs 3ailasts Wirinc No.:Hyaro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant ;o the reautrements of %1assac'users general Laws I have a current Liapiiity Insurance Policy inciucmg Comte^:et eerauons Coverage or its suostanual eauivaient. YES have suomittea valid proof f same to the Office. YES — NC — it you have checxea YES. please inaicate the type of coverage by checwng the ap rop pox. INSURANCE — BOND = OTHER = (Please Scec:fy) (Expiration Date) Esumated Value of E'.ectrical Work s Worx .a Stan Insoection Date Recuesec. Rougn Final Signeo unser the Penalties of perjury: FIRM NAME ' ,�✓ 7-/7z y LIC. NO. Licensee 3 /% r- � Licensee Signature /? " LIC. NO. Bus. Tet. Address r D S•w/�iCJ` % / .�L®s/�i zG/+/C� / Alt. T I . o. OWNER'S INSURANCE WAIVER: I am aware that the Licensee Coes not have the insurance coverage or its suostanual eauivalent as re- ouiree by Massachusetts General Laws. and that my signature on :.^.is permit application waives this reauirement. Owner Agent (Please cnecx one) Teteonone No. PERMIT FEE 5 iSignature of Owner or Agent) x-5565 ��. �..�,..,..ny„a�,wr,..�-.�.-W�-'�` ....: �,.. -�: �r,`.�yKr...:+iti—.^...y:•.�` �•'�L..;�;:r---''yrs ��..,-..f4.r:.--..zv_«--..�.r.•-...:i... *� .266Date... .�1.`qi... NORTH TOWN OF"% jN,,ORRJTH ANDOVER 0r pp PERMIT FORS INSTALLATION This certifies that .. 1. .'. 4 ... has permission for WSn ms lation . ..... . UL - in the buildings of ...... . . ......... at .�i.....' . , North Andover, Mass. �. q �® Fee.,��! Lic. Nd �./ i8 / ..Vrk*A- I06/13/ PAID WHITE: Applicant CANARY: k wilding Dept. PINK: Treasurer GOLD: File