Loading...
HomeMy WebLinkAboutMiscellaneous - 4 KATHLEEN DRIVE 4/30/2018N Location oo No. -A Date 2 v AORTp, TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ v CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r 1 CA9 Building Inspiector ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING s •� g�R , 3 $ �� f d. �� � � i� �y'f$a'�&Sg��aa . d A, �i uf'e4xyreG �.�` d BUILDING PERMIT NUMBER:q DATE ISSUED: & SIGNATURE: / st Building Commissioner/IREL=tor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BURRING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required— Provided Required Provided 1.7 Water Supply M.G.1—C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record roof/ Name (Print) Address for Service: G/75— 3 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: ` I Si `ature Telephone SECTION 3 - CONSTR TION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ 7`0m cT 736 /9' Licensed Construction Supervisor: License Number . Address Yq0 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 �,% Name Company Registration Number 7 V 7/� / %.2 Address [Q 6,3 ���� / ! S (�,✓ Expiration Date Signature Telephone 1�6 SECTION 4 - WORKERS COMPENSATION (M.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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OI+TLt�L�USE:Ot+jLY 1. Building r (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction , / D ` `� � r 3 Plumbing Building Permit fee (a) X (b) �-- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN -T OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH.DING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My beh f, inmatters relative to work authorized by this building permit application. Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3kD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City 19I)I W fl -2 f l�l�� d `U Phone am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity am an employer providing workers' compensation for my employees working on this job. Company as '.�✓_� .� - :•lis Irk . `1 Address city. N. Phone #- l0 3 76 Y iv�vvvvNt/�,Q V Company name• Address City- Phone #- Insurance Co Policy # 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 andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby 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' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 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: 6107e CO AJ .� cfkJ Facility location ©306 Signature of Applicant b& Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. 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 �1 f �� - ��% PHONE '7 ?� y%S C3'�(o CD ASSESSORS MAP NUMBER SUBDIVISION LOT NUMBER c5F NUMBER STREET / �-/d ' !2 G 1JL, -- STREET NUMBER #7 / OFFICIAL USE ONLY REC N MIENDATIONS OF TOWN AGENTS DATE APPROVED CdNSERVATIOMADMINISTRATOR DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR - HEALTH t ...e►t 15e v' SEPTIC INSPECTOR - HEALTH COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT OMNI"., 06"M007 DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR 4 Kathleen Drive Andover, MA ' 1-T S ,-7, szo �± BUYER: C �L-Y• p-I'N1-4 i DIAV,)s To Pie ( //\AIN ST //bP-TGAGE. AND ITS TITLE ItMJRERS. ro m U 0 J n 0 MORTGAGE INSPECTION PLAN LOCA7W IN I CERTIFY TIIAT I IIAVE EXAMRIED PIE PREMISES AND 'PIE BURDINOS 51004 DO CONFORM TO 111E Z0111110 LAWS AND AMENDMENTS, I.R(FRONT, SIDE, k REM YARD SETBACK ONLY OF"t1 vU I` R -WHEN CONSIRUCTEU. 1 FURRIER CERTIFY PIAT PUS PROPERTY IS �AO'T LOCATED RL PIE ESTABLISHED MOOD HAZARD AREA. COI.IMINNITY PANEL NO.: 25001 to • oo 10,& DATE: a- I - %8 EXAMINATION OF PIE RECORDS IS MADE ONLY SUBSEQUENT TO PIE RECORDED DATE OF PIE LATEST DEED AND DOES NOT RIgUDE VERIFYING PIE ACCURACY OF PIE DEED DESCRIPTIOtf PREVIOUS TO ITS DATE OF RECORD. PIIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MME SUBSEQUENT TO WE RECORDFD DATE OF PIE LATEST DEFT) OF RECORDED. M!!ASSAC IUS,ETTIS B�r� 174 PAGE 789 CFR T. NO. "IENEVEL BUILDINGS ARE SlIOV41 LESS PIAN CITE FOOT FROM PIE ('ROPERTY U11E IT IS ADVISED PI-Ai1 BK PAGE THAT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE MEASUREMENTS. PIAN / (592 DATED Mm 7111S CERTIFICATION IS BASED Off PIE LOCATION OF SURVEY MARIO:IIS OF OPIERS, AND DOES NOT REPRESEfT A PROPERTY SURVEY. THIS CERTIFICATION TO BEklaw- FOR MORTGAGE PURPOSES ONLY. scAtF: t �f OFFSE tT OF F E NOT TO BE r' 7 USED FOR 11 ABUSII F PROPERTY LINES "F FD G BRADFORD CTTARF,TTT ENGINEERING CO. P 15799 P.O. BO)f 1144 FRED W. C Ilit LOA. 01831 R.L.S. #15755 1 - IIAM(60R) 371-1306 H41 RV E�,. I c o as c .`c c v o � c ` O N r.. C 16: d� c 46 c m� S H E c o CO �cit: c� 0 0 .E �mmCL t a N O O V mCD cc o 0 acs L -:m N 0 w cc C o Q d cm C m O o � V•N�Z cm c o c H m C •C _ m C's rt.. p f V f— o COO C 4; O w o .� M at"c Z fzE 5-0CDo v m om=c g CO) d 0. 0:6 S .0 om O f- Z +O+ d r, m ? a h•V �J CD O CD Z O G I ti CD C� L CL CD 0 CD Q m 2-rrL rA O V .,a CA c O V CO p� c c IM N m m W 0 w Ir LliLU LLJW Cn c° a cn O C � w °7° m7 w a O U a°' cz uz � O W W a°' cn ro w O H 7 a°' ro w W m' cn V) c o as c .`c c v o � c ` O N r.. C 16: d� c 46 c m� S H E c o CO �cit: c� 0 0 .E �mmCL t a N O O V mCD cc o 0 acs L -:m N 0 w cc C o Q d cm C m O o � V•N�Z cm c o c H m C •C _ m C's rt.. p f V f— o COO C 4; O w o .� M at"c Z fzE 5-0CDo v m om=c g CO) d 0. 0:6 S .0 om O f- Z +O+ d r, m ? a h•V �J CD O CD Z O G I ti CD C� L CL CD 0 CD Q m 2-rrL rA O V .,a CA c O V CO p� c c IM N m m W 0 w Ir LliLU LLJW Cn WT 0 am Iz c o as c .`c c v o � c ` O N r.. C 16: d� c 46 c m� S H E c o CO �cit: c� 0 0 .E �mmCL t a N O O V mCD cc o 0 acs L -:m N 0 w cc C o Q d cm C m O o � V•N�Z cm c o c H m C •C _ m C's rt.. p f V f— o COO C 4; O w o .� M at"c Z fzE 5-0CDo v m om=c g CO) d 0. 0:6 S .0 om O f- Z +O+ d r, m ? a h•V �J CD O CD Z O G I ti CD C� L CL CD 0 CD Q m 2-rrL rA O V .,a CA c O V CO p� c c IM N m m W 0 w Ir LliLU LLJW Cn ' � :Mitt? tra)�9�tnstc��. r1&�lj £�tt �• �s�-=Et�T��'. BOARD OF BUILDING REGULATIONS- i License: CONSTRUCTION SUPERVISOR I = Number. CS 073018 Birthdate: 0413011963 Expires: 04/30/2002 Tr, nes: 73018 Restricted To: 00 THOMAS J EDWARDS _ 12 UNION STREET' f DERRY, NH 03038 Administrator �3 1 _= NOME IMPROVEMENT CONTRACTOR -, Registrations 122159 Expiration: 7126.102 Type: Private Corporatio I.J. EDWARDS S SONS, INC Thous Edwards, Sr 9 UNION STREET A6h INISTRAIJOR DERRY NN 63038 IV N2 2377 17 Date......... . ;/ ......... I ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... Ro�j-,, � Lq v� , u, �,? , �7- ip �- ............ ...................................................................... ........................................... has permission to perform ..... .............. wiring in the building of ........ ..................................................... at ....... 9� ... /- -� //- '- -1 ...... . North AM er, M ........................................ //. 1yo CIL/ 37V,1 0 Fee..................... Lic. No . .......... ...... ......... L INSPEc-rOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .4 41-ocation 171 No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check 1 37'0-'- 5 BZ'fldin-g Inspe ��G(r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / DATE ISSUED:co SIGNATURE: Building Commission for of Buildings Date SECTION 1- SITE INFORMATION - 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40: 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service :t / p Signature Telephone 12.2 Owner of Record: U� Name Print Address for Service: c G V Si nature Telephone SECTION 3 - CONS . UCTION SERVICES 3.11 Licensed Constructiob Supervisor: Not Applicable ❑ J Licensed Construction Supervisor: License Number Address 110, - il5 Expiration Date Snature Telephone 3.2 Registered Home IImprovement Contract/or Not Applicable 0 Company Name Registration Number 9 /.fes, vn s� Address / 00, -11�94 &�� Cation ISate Si natur Telephone vu SECTION 4 - WORKERS COMPENSATION (M.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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all a Ucable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition )< Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 4- ForC_17 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be OFFICiASE �CTI�ILY , Completed b emut a licant u. 1. Building (a) Building Permit Fee —� v-52"'. Multiplier 2 Electrical (b) Estimated Total Cost of l /� `7 Construction / 1 3 Plumbing p Building Permit fee tel x (b) 4 Mechanical AC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 46 as Owner/Authorized Agent of subject property Hereby authorize9,9umQS _J W45 5 to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ]Z4d ;�P�'ic ?0Yd S 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 a / Sitt e of Owner/ ent Iqk Date'/ NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS i ST"7KA9 2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS �- DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION' THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: �a S am a hom owner performing all work myself. 01 am a sole proprietor and have no one working in any capacity Gemma` 44- D l -c'�,G'I9111- aI 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 Policy # 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 penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certifyynder the pains and penalties of perjury that the information provided above is true and correct. Print Official use only do not write in this area to be completed by city or town official' []Check if immediate response is required Building Dept # A03 Contact person: Phone A- r -1 : FORM WORKMAN'S COMPENSATION ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM NORTH 0f itL80 ;6 q Y� O y CO[NI,Iy WK• V 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, sl 50a. The debris will be disposed of in /at: Facility location ignature of Applicant Date i E NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta �==� Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE�y . s /,�b JOB LOCATION / 7WZ Number Street Address "HOMEOWNER &AV& C/ 77` ,6/9CC& 4.1 C� Name Home Phone PRESENT MAILING ADDRESS Map / lot Work Phone City Town State Zip Code 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 understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S APPROVAL OF BUILDING OFFICIAL FORM - U - LOT RELEASE FORM I 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 2,tte ,, at, -y , PHONE J%g— D j� ASSESSORS MAP NUMBER ?.S LOT NUMBER SUBDIVISION LOT NUMBER STREET STREET NUMBER OFFICIAL USE ONLY RECOMN ENDATIONS OF TOWN AGENTS S,t-- A) Wit.. "r DATE APPROVED CONSERVATION ADMINISTRATOR ( DATE REJECTED L Z COMMENTS `vl.Q Orr= or RIDA DATE APPROVED TOWN PLANNER DATE REJECTED CONINIENT S DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT F1MIq000.Z0P/4117 FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR TE 2 5 2000 A Y r 4 Kathleen Drive Andover, MA k,01 t'oT 3 -L-T S -L c>T Co f I %off )( lI I ( 30. 14 - - i41 91 j�MORTGAGE INSPECTION PLAN c � �Y, L)l AnIE BUYER: J 2ft�f LOCATED IN �� �''�/ EJ"z To PIE (- //\LN 5T IA<D I'TG AG c AND ITS TITLE IISITRERS. MASSACI IUSEIIS I CERTIFY THAT IHAVE EXAMINEII WE PREMISES AND TIIE BUILDINGS SHOFAR DO ( CONFORM 1D T11E Z0111110 LAMS NN AMENDMENTS, I.a(MONT, SIDE, M REM YARD SETBACK ONLY OF /1-"1=,- oma/ L Fz- `' WEN WISTRUCTED. I FURTIIER CERTIFY THAT 71119 PROPERTY IS X01 LOCATED DI 711E ESTABUSIIED FLOOD DEED INA7AIRD AREA. COMMUNITY PANEL NO.: 250014o • 00 10Q. DATE: 6- I - %6 ' 7��- BOOK EXAMINATION OF 711E RECORDS IS MADE ONLY SUBSEOUEIT TO WE RECORDED DATE OF VIE PAGE789 LATEST DED AND DOES NOT INCLUDE VERIFYI NO TIIE ACCURACY OF 111E DEED DESaUPTIgN PREVIOUS TO ITS DATE OF RECORD. CERT. fNO. TIIIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUEIT TO 711E RECORDED DALE OF THE LATEST DEED OF RECORDED. VATENEVER BUIIDIHGS ARE STOLEN 1E55 TIIAN ONE FOOT FROM TIIE rROPERTY UNE IT IS ADVISED MANN M PAGE TIIAT A MORE PRECISE SURVEY BE MADE TO VEDFY TIIESE MEASUREMENTS. PUN 1 5"'2 DATED NOTE: 7111S CERTIFICATION IS BASED ON PIE LOCATION OF SURVEY MARKERS OF OTIIERS, AND DOE'SAt)G -7T ZI NOT REPRESENT A PROPERTY SURVEY. , 1091 1111S CERTIFICATION TO BE FOR MORTGAGE PURPOSES ONLY. SCANS: t-.. tlpN OFFSE y�:�1 of . F E NOT TO BE n-" •_• 7, USED FOR 11 ABLISH F PROPERTY LINES FRE. BRADFORD CHASF'TIT N 157q!3 ENGINEERING CO. r � 4 P.O. 60X 1244 IIAVERIIILL MA. 01831 FRED W. C it' '.�' R.L.S. X15753 tfL (we) m-2306 x w u a w z cc w Pw ao' m a p u w w W o a p U wUD o z w a aA A w v CO ° z ci) o ° C/5 c� c � o c • : «. O CCO,v :A 4 A&,. c ea ` Aoio E a C/) 10 mu �t :�co a� 2 E S O MCD C' o mc E m oN CM —;m C W N; j-=: N O O v E N M r:oo i Y CLC -SCD � —W z c cm •� N (19:�: p,Ct �� O m :r �: COi •y O r. — O •> Z O c •O S m '�' a� p N COD C ea Z O •N O /a /a O F- h CL= . c Z S « C •N O V •CO o m 0 cm 10 ci Vi a CD O S C13C2 y•� O F- t +0.. a_..m O O b.0 O � I y aA LA O .E o a Q v � O v 4-4 _cc N h � O O V O cc d CO2 0 3� Q d �a •= C O J•O O O Z co C. CO) C 0 U) U) crW w LLJW U) 122:'13,`1996 08: 28 60 8869640 CIT`1' (-JIDE ELECTRIC �� PAGE 02 L hlb Commonwealth Of Massachusetts office u,. only ; t y?; Depaivnent of fvtsflc S(ON BOARD OE FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy i Fa* Ch.ckee�/eJ st90 (leave etant} APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK I,u Sao 10 Ga Wod yr occfxd, +v; w� )laaaeshusana diar "Gado, sit CIA 12:00 - (P4SASe PPiN i IN INK OR TifPE ALL iNPORMATION i7ate City or Town of_ ?v0, ANDO%IER - -- - To Ina Inspector of Wlrea: The unoer3igned appii#s far a permit to perform the electrical work described below. Location (Slrrel b Numoer)_- 4 KATHLEEN DRIVE owner or Tenant BRUCE CkRKyv.,_- 4+ i .THLE'EN DR- ANDOVER, IDSA' owier's IS thle permit In Conjunction with ■ building permit yes. Cl no 0 (Ch l A Appropriate box) Purpose at Ouitu'inq__�. Utility Authorizalion No.___- _. _— - _ . 604287 ExlsiJng Servic® -�4mPs�.r� IVatts Overhead 3 Undgrd � No. of Met•re•_,_•_, New Service _— temps- Volts Overhead ❑ Undgrd ] No. of M@tera__ Number of Pseders and AmpaClty Service. Change 100 Amp Cable to 10OAmp PVC/ Minor Repairs Location and Nat of Proposed Electrical Work No. of ii htin Outlets No. of Hot TuOs No. of Transformers TAI. KVA Above in {''� ❑ ❑ No. of Lighting Fixtures Swimming Pool rnd, rnd Generators KYA No. of Emergency Lightinp NO. df Rete Loci• Outfeta No. of Oil Burners Battery units No. of Switch Outlets NO. of Gas Burners FIRE ALARMS No. al Zones TOTAL No. of 0itection and No. of Ran es No, of Air Conditioners TONS Initiating Devices BEAT TOTAL TOTAL No, of Sounding Devices No. of Dis Deals No. of Pum s; TONS KW No. of Sell Contained Detecuonl5ounding Devices No. of Dishwashers S acelArea Heating KW No. of o ers I'latfulingLOevices KW Muntdpal _ s LOCal ❑ Connocllon ❑ Other Na. of No. of Low Voltage No. of Water Heaters KW Si ns Ballasts Whin No. of H dro Massae Tubs No. of Motors Total HP OTHER; INSURANCE COVERAGE: Pursuant to 1110 requirements of Massachusetts General Laws r ' I have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES -,:S: NQ -C] I heave submined valid proof of same to this office. YES IS NO O - It you have checked YES, please indicate the type of coverage by checking the appropri I0 box tF �-i I INSURANCE ® BOND 11 OTHER 0 (Ply@, `e Spec�ty) y Ljl� I I' ^;� (>;xpi(allon pets) i t. Estimated value of Electrical Work 3._ - Work to Stan inapectivn Data Re4Ue3104: Rough Finyf Signed under the penalties of perjury: FIRM NAME CITY WIDE ELECTRIC LIC. No. 578MR Lidenase ANTHOD rj LEMIRE Signature LIC, NO.E166SO � 4 JACKSON DRIVE. HUDSON, NH .03051 Bus, tail, No.603/886-4640 Address�--- " All. Tel. Nd, OWNER'S iNSURANCE. WAIVER: I ern aware that the Licensee does not have the ineurancs coverage or Ila substantial "uNalsnt y rK7utred b Mass•onus•lU General Laws. and that my signature on this apfs 1C9110n walvey thin requirement, owner Ageni (Pteaae Check on�e) T•i•phgne Nd, P$�tMffi FEE iSignswre of owner or Awl) ��� G� - 71