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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............
.
.........................................
.......................................
has permission to perform ...
. ...................................................................
wiring in the building of ........ ...... ...............................................
at ... :::: ................... ......
. .. . .......................... North Andover, Mass.
Fee.............. Lic. ... . ....... .................... ..............
ELECTRICAIIINSPECfO'R
Check # -? 3 ';/,K) U
110irk
45- Ij z 7
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. C7
Occupancy and Fee Checked /09
[Rev. 9/051 (leave blank)
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: )-)`7-0 �
City or Town of: �) y '� To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) -�> -) } jfr� p L
Owner or Tenant
Owner's Address
o1b
Telephone No.
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building tS10)5 1., C Kl Utility Authorization No.
Existing Service -�)OO Amps ]�-6 / a 0 Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed gElectrical Work:'�L���
Completion of the followine table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
Tr o Tota
Transformers KVA
No. of Ldminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In-
rnd. grnd.
No. of Emergency Lignting
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
InitiatingTotaDevices
No. of Ranges -�
No. of Air Cond. Tons l
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number.
Tons
KW
No. oSelf-Contained
Detection/Alerting Devices
No. of Dishwashers ]
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or E uivalent
No. o Water KW
Heaters
No. o No. o
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
7
OTHER: U �,b c-,%(3 L G
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 16660,—. (When required by municipal policy.)
�
Work to Start: I f a, 5- d - 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: INSURANCE 19 BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and pens ties of perjury that the information on tills applic ion is rue and complete.
FIRM NAME: cl.)fZt1S f
Licensee: �)apy�,� ��� Signatu LIC. NO.: jj
(If applicable, ent r "exempt" in the license numb e line. Bus. Tel. No.: o�
Address: %� b � v d Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
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:
/09_
NORrH
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Date
TOWN OF,NORTH ANDOVER
PERMfT FOR PLUMBING
This certifies that ..' h�? .r..�... G.aa . ti.. ...... .
has permission to perform ..... �� �. `.� �. v+ {'. ` .............. .
plumbing in the buildings of .. .. .................
at ...3 ?...G.� Y. fir? r..� .. �. �............. North Andover, Mass.
Fee.Lic. NoJ.1 ! .... ..... .... '""�.�-- .......
% PLUMBING INSPECTOR
Check *
Y'a2
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) (
NORTH ANDOVER, MASSACHUSETTS
Building Location 3--�' dl y tLw:�2jG Lq e Owners Name
of
New Renovations Replacement 0
r1rVgrr1nr. v
Date / J U0
Permit #
Amount 12 -
Plans-
Plans Submitted Yes ❑ No ❑
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(Print or type) Check one:
Installing Company Name Certificate
❑ Corp.
Address 3 i
Partner.
Business Teleptiond,
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate th ype of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ 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
Signature I Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perf rmed under Permit Is ued Cor this application will be in
compliance with all pertinent provisions or the Massachusetts StaTO4
Code a Ch ter lZ of the General Laws.
By: igna ire Of is se um r
Title
Type of Plumbing License City/Town G
teen er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
Date ... 2
lwd4l f: ........
0 * NORTH6
06 TOWN OF NORT ANDOVER
lA 41
PERMIT FOR GAS TALLATION
This certifies that s....
has permission for gas installation .... P.r.t't 5.:t ..............
in the buildings of ...�.A. r. 5. 4 !:'(� .........................
at t-.......... , North Andover, Mass.
Fee. Y ... Lic. No. J. Z .1. r .. .... .......
GAS INSPECTOR
Check#
5631
A
MASSACHUSEIIS UNIFORM APPLICATON FOR PERMIT TO DO GAS FIT'T'ING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New ❑ Renovation Replacement ❑
Date ?—/-7 OG
Permit # _ 's—co 1
Amount $ 30.
Plans Submitted
(Print or type)/„� 3
Name �"!!!
Address
Name of Licensed Plumber or Gas Fitter
1 Check one: Certificate Installing Company
Corp.
ElPartner.
Firm/Co.
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes W No
If you have checked Yes, pleadicate the type coverage by checking the appropriate box.
Liability insurance policy0 Other type of indemnity 1:1 Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 1:3 Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform9iunder Permit Issued to this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas and Chapter 142 of t General Laws.
By:
Title
City/Town
OVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas
0 Plumber
RGas Fitter Licene Nu7 e
Master
Journeyman
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SUB -BA SEM ENT
B A S E M ENT
1ST. FLOOR
2ND. F L O O R
3RD. FLOOR
4TH. FLOOR
5 T H. F L O O R
6 T H. F L O O R
7 T H. F L O O R
8TH. FLOOR
(Print or type)/„� 3
Name �"!!!
Address
Name of Licensed Plumber or Gas Fitter
1 Check one: Certificate Installing Company
Corp.
ElPartner.
Firm/Co.
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes W No
If you have checked Yes, pleadicate the type coverage by checking the appropriate box.
Liability insurance policy0 Other type of indemnity 1:1 Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 1:3 Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform9iunder Permit Issued to this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas and Chapter 142 of t General Laws.
By:
Title
City/Town
OVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas
0 Plumber
RGas Fitter Licene Nu7 e
Master
Journeyman
Date.. . . ...............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .: ........ .... :' ..... —' '............ .
has permission for gas installation ........;::c-!
in the buildings of ............. ' ' ........................... .
at ............1. North Andover, Mass.
Fee::."...`.. Lic. No •.:�. 77'� _! .. .. ........
GAS INSPECTOR
Check #
3
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
SC) c W lc
Owner's Name
New ❑ Renovation Ej Replacement ❑
Date A �L-0-0
Permit # �/ "3 `
1 Amount $ 20
Plans Submitted ❑
(Print or type) ,,�"
Name pyeyte11V4C -�' AJ f`
s
Address i /fir✓� �J /��^(
Business Telephone 7 7 F-- 37.
Name of Licensed Plumber or Gas Fitter D�
A �S
ffone: Certificate Installing Company
Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes M'_ No❑
Ifyou have checked M, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner -1 Agent ❑
I nereby certlty tnat all of the details and intormation 1 have submitted (or entered) in above application are hue and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
(Title
City/Town
(OFFICE USE ONLY)
Signature of
❑
Plumber
❑
Gas Fitter
❑
Master
Journeyman
i
•
(Print or type) ,,�"
Name pyeyte11V4C -�' AJ f`
s
Address i /fir✓� �J /��^(
Business Telephone 7 7 F-- 37.
Name of Licensed Plumber or Gas Fitter D�
A �S
ffone: Certificate Installing Company
Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes M'_ No❑
Ifyou have checked M, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner -1 Agent ❑
I nereby certlty tnat all of the details and intormation 1 have submitted (or entered) in above application are hue and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
(Title
City/Town
(OFFICE USE ONLY)
Signature of
❑
Plumber
❑
Gas Fitter
❑
Master
Journeyman
;ed Plumber Or Gas Fitter
(cense Number
..Location
No. ��z? O 1 Date �J
NORY" TOWN OF NORTH ANDOVER
O
i s
+ ; , Certificate of Occupancy $
cMUSEBuilding/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 11242-
Check # 1-1
i4-31
Building 144ector
4'
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
' ..
BUILDING PERMIT NUMBER: 2 �a► DATE ISSUED: /I-
SIGNATURE:e
Building Commissioner/Insmaor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
Q(t t
1.2 Assessors Map and Parcel Number:
p Number NjParcel Number
Y V ili C / 0 i J
1.3 Zoning Information:
Zoning Distrid Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS 00
Front Yard Side Yard
Rear Yard
ReqWred Provide RegWred Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
.SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print z111Address for Serl4e : I 14
QAP 975�� 3�
�
Signa a Telephone
2/Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
IAidress
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
00
rn
X
Z
O
SECTION 4 -WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faili
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing B1'(tiding ❑ Repair(s) ❑ Alterations(s) ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
5�,k 4-
I SECTION 6 - ESTIMATF,D CONSTRUCTION COSTS I
to provide this affidavit will result
Addition ❑
ill
WA
Item
Estimated Cost (Dollar) to be
Completed b ermit applicant
OFFICIAL USE ',ONL
1. Building
'
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinZ
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
OWNERS 7�ER
GENLOR CONTRACTOR APPLIES FOR BUILDING
as
V
authorizealf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
zed Agent of subject property
to act on
1, 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
Print Name
Signature of Owner/Agent Date
l
0
.(^ t pORT{r
Town of North Andover ° t ° '• �"
Building Department p
27 Charles Street ossa
North Andover, MA. 01845 ��s ..'a,9
SA S4
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print. /
DATE �w
JOB LOCATION
Number Street Address
1— j Al
"HOMEOWNER
PRESENT MAILING ADD
City Town
Home Phone
Map / lot
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 one home 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 he/she u rstands the Town of No. Andover
Building Department minimum inspection procedu nd requirements and that she will
comply with said procedures and requirern w
HOMEOWNER'S
APPROVAL OF BUILDING 0
Code
Town of North Andover tkaR=y
Building Department o
27 Charles Street,
North Andover, Massachusetts 01845;'m
(978) 688-9545 Fax (978) 688-9542 9 "`�"�'w
A°A�reo �Pa(c3
9s�►u,�Sgcs�
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in /at:
Facility location
Signat 9f Applicant
�—
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
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ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFMING
(Pmnt of Typel
ig '52- Permit %J
Budding Locatlon 2 �� /"F Owner's NameT)sF0 wets D
Type of Occupancy '(�r hCJt'
New [3/ Remyratlon ❑ Replacement ❑ Plans Submitted: *es❑ No [g�e
r /aJ Check one: Certificate
installing=Company Name -(
Address / Corporation
fp hx f, C3Partnership
Business Telephone ,6d .-Is Z) Z c�& Firm/Co.
Name of Ucemed Ptumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability irut rance policy or its substantial equivalent which meets the requirements of MGL Ch. 1A2.
Yes C3 No ❑
K you have checked res, please indicate the type coverage by checking the appropriate box.
A liability insurance policy G Othertype of indcmnttY a Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee d0es_not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement
Check one:
Owner❑ Agent ❑
Sigruture of Orman or Ownw's Acsnt
I herby certify that all of the details ata' Worrution 1 hays submitted for entaredl in above apptication an that and accurate to the• best of rry
krowiedge and that all plumbing worst and ktztwtatioru performed under the pemut i&w9d tot tttis application va be in Cmptiancs with ail /
pertinent provisions at the LUmaclusetts State Gas Coda and Chapter tt2 of General Laws.
6/ TYe of Lkmn=:
Ptumbet nature o rased ,umoer or Rtat
TrueA C tSatr Lk2rus Number Z �.• • 6" r
Cty/io„ny .7oumsyman
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SUB—ESIAT.
EASEMENT
IST FLOOR
2.40 FLOOR
3RO FLOOR
ATM FLOOR
S Th FLOOR
6TH FLOOR
I
7Th FLOOR
8Th FLOOR
r /aJ Check one: Certificate
installing=Company Name -(
Address / Corporation
fp hx f, C3Partnership
Business Telephone ,6d .-Is Z) Z c�& Firm/Co.
Name of Ucemed Ptumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability irut rance policy or its substantial equivalent which meets the requirements of MGL Ch. 1A2.
Yes C3 No ❑
K you have checked res, please indicate the type coverage by checking the appropriate box.
A liability insurance policy G Othertype of indcmnttY a Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee d0es_not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement
Check one:
Owner❑ Agent ❑
Sigruture of Orman or Ownw's Acsnt
I herby certify that all of the details ata' Worrution 1 hays submitted for entaredl in above apptication an that and accurate to the• best of rry
krowiedge and that all plumbing worst and ktztwtatioru performed under the pemut i&w9d tot tttis application va be in Cmptiancs with ail /
pertinent provisions at the LUmaclusetts State Gas Coda and Chapter tt2 of General Laws.
6/ TYe of Lkmn=:
Ptumbet nature o rased ,umoer or Rtat
TrueA C tSatr Lk2rus Number Z �.• • 6" r
Cty/io„ny .7oumsyman
0-
Date .... �....// r .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..............
has permission to perform
wiring in the building of .....'......"...................................................
at......................................... .-.... /�............. �.. , North Andover, Mass.
Fee`..... ............... Lic. No.
..........................................
-ELECTRICAL INSPECTOR
�
Check # ' /
49A
Ir
TTE COWWO.9 WEALOfO(F91tX C VWgtrs
Department ofTuMxSafety
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Official Use
� Only
9
Permit No. `�' 90,3
j
Occupancy & Fee Checked -K "
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All . work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print In ink or type all information)
Date^ — �J
To the Inspector of Wires:
Town of North Andover 11 19
The undersigned applies for a permit to perform` the electrical work described below.
Location (Street & Num—beer
Owner or Tenant �ac� % ids �,f3
Owner's Address • 1�4�(`� L�
Is this permit in conjunction with a building permit Yes No 0 (Check Appropriate Box)
Purpose of
Existing Service t_{1 Amps_l��Voits Overhead
Authorization No.
Undgmd 0 No. of Meters
New Service Amps Voits Overhead 0 Undgmd 0 No. of Meters
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES r No 0
have submitted valid proof of same to the Office YES C% NO C, If you have checked YES please indicate the type of cb
INSURANCE BOND C, OTHER 0 (Please Specify) J by checking the appropriate box
Estimated Value of Electrical Work$ I � 3 (Lipiration Date)
Work to Start Inspection Date ResquestedRough r �C %) Final
Signed under -the Penalties of Deriurv:
FIRM NAME r
LIC. No. 4= %
LIC. NO.��2-Ifa
— 7 / y� j Bus. Tel No. �%X/ LS%.j 6 J00
Address / b 5A k 6 (LJd) Ug /,y "',/ 0A Aft Tel. No.
OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $ \aV
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
y�
Above
I0
No. of Lighting Fixtur /
SwimmingPool
mdd 0
md0
Generators KVA
/_
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No.
Pumps
Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Area Heating
KW
Detection/Sanding Devices
0 Municipal 0 Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES r No 0
have submitted valid proof of same to the Office YES C% NO C, If you have checked YES please indicate the type of cb
INSURANCE BOND C, OTHER 0 (Please Specify) J by checking the appropriate box
Estimated Value of Electrical Work$ I � 3 (Lipiration Date)
Work to Start Inspection Date ResquestedRough r �C %) Final
Signed under -the Penalties of Deriurv:
FIRM NAME r
LIC. No. 4= %
LIC. NO.��2-Ifa
— 7 / y� j Bus. Tel No. �%X/ LS%.j 6 J00
Address / b 5A k 6 (LJd) Ug /,y "',/ 0A Aft Tel. No.
OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $ \aV
(Signature of Owner or Agent)
Name:
Location:
CitV 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.
Com an name:
Address
Ci : Phone #:
Insurance Co Policv #
4'
Compgny name:
Address
Ci : 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 $1,500.01
and/or one years' imprisonment as well as_civil,penaltiesinlhefnrm.da STOP WORK ORDFR.and a fine -of _($V-0.00)aAaY.againsi-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 certify under the pains and penalties of perjury that the information provided above is true and correct.
�i
Signature Date �
Print name
Phone #
official use only do not write in this area to be completed by city or town official'
Permit/Licensirt
City or Town
❑Check if immediate response is required
Contact
LJ Building Dept
p Licensing Boar
Selectman's 01
Fi Health Depan`n
F1 Other
'6
Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
CL
This certifies that .../ . .(f
has permission for gas installation
........................
in the buildings of . ...................
at �h Apdover, Mag.
Fee.., .? ::... Lic. No.� .......
GAS INSP INSPECTOR
WHITE: Applicant CANARY: Building pt. PINK: Treasurer