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Miscellaneous - 41 CEDAR LANE 4/30/2018
J41 CEDAR LANE 210/106.A-0146-0000.0 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �o M MA DATE _ 2 _ PEtT JOBSITE ADDRESS OWNER'S NAME p OWNER ADDRESS KIC��� , � � � TELFAX _ ,, y . . v.A..- TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: 'REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES I FLOOR--3 BSM 1 2 3 4 5 6 7 8 1 9 10 i1 12 13 14 BATHTUB , .1= --- CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOtLISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN - _FOOD DISPOSER I I � FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK - LAVATORYJ . 4 1 ROOF DRAIN SHOWER STALL .._._ _ -- SERVICE IMOP SINK TOILET URINAL I F WASHING MACHINE CONNECTION - WATER HEATER ALL TYPES . WATER PIPING OTHER L _ { INSURANCE COVERAGE, I have a current 111blillyInsurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YESI NO IF YOU CHECKED YES,PLEASE INDICATE T PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY . ! OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE V R:I aw hat the If s do gji tp have the Insurance coverage required by Chapter 142 of the Massac etts otter L ,a hat Igna permit application AgLyes this requirement. CHECK ONE ONLY: OWNER AGENT SiGNA RE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that ail plumbing work and Installations performed under the permit issued for Ibis application will be in coplMnco with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Lem. y PLUMBER'S NAME �` vSt' j LICENSE# /� l� SIGNATURE MP_- JP CORPORATION S#=PARTNERSHIPS#=LLC # COMPANY NAME - CITY .i1rh 1 - - STATE 1 4���- zip TEL FAX E=CELL . oZoc�( MAIL r The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Stilts 104 Boston,MA 0211412017 luwlt.ntass.govldia Workers'Compensation Insurance Affidavit:BuildeislContmetors&lectricians/Plumbers. TO 4FMB WITH THE PERMITTING AUTHORITY. Agnliga.t nfo stip _ Please Print Legibly Name(f3usiness/Organ xationflndividuat: Andress: 40,4, � ( oa-,-.- L. City/State&ip: « .01` 0:2 Phone#l: GQ3 4,)C-e9%QA Are you an employer?Cheep the atpproprhte boa: Type of project(required): i.EJ I am a employer with employou(full and/orpart-time)_* 7, O Ne ristruction 201 am a sole proprietor or partnwb p and have no employees working for me in 8 emodcling any capacity.tNo workers'camp.ins—tee required.) 3.01 am a homeowner doing all wale myself:tNo v wkeW camp,insurance required.)t g• F-1 Demolition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my property.I will 10Building addition tat are that all contractors either have uwkers'contpensalion insurance or arc sole l l.1_.t©Electrical repairs or additions proprietors with no employcer. 12,[3 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-corthaetors listed on the sttaahed sleet These subcontractors have employees and have workus'comp_insumaml 13,[]Roof repairs 6,0 We area corporation and its officers have etrctcised their right of xemption per MGL e. 1.4.n Other 152.61(4).and we have no employm.[No workers'comp,inntrarce required.] •Any applicant that checks box#1 must also fitl aattho sedion below showing their anrktn'compmMlion policy information. t Homeowners who submit"affidavit indicating they are doing all work.and than him outside contractors mus submit a new affidavit indicating such. tContiactors that check this box rmust sttached an additional street showing the name of the sub-contraetors and state Whether or not those entities have employees. If the sub-contrsstors have err pkri es,they must provide their vwkera'camp.policy number, lam an entplayer drat#s providing workers'cortrpensatioir itrsrarance far ttty enWleyees. Below is the policy and job site information. Insurance Company Nome: Policy#or Self-ins.Lie,#: Expiration Date: Job Site Address: City/Statetzip: Att€ich a copy of the workers'compensation policy declaration!sage(showing the policy number and expiration date). Failure to secure coverage as required udder MGL c. 1.52,§25A is a criminal violation punishable by a fine tip to$1,500.00 andtor one-year imprisonment,as well as civil penalties in the farm of a STOP WORD.ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I rid hereby cert fy the pains an1djuzWdes ofnerjuty that Me information provided above is trite and correct &MM* . Rhotic#: 0-':^ G4`14�) Z v Official use only, Do not write in this area,to be cooWleted by city or tmvrt offidal. City or Town: Permit/License# Issuing Authority(circle one): I..Board of Ifealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector ti.Other Contact Person: Phone M DD 1) ate............................................ TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ss�CHU This certifies that��Q\-A ............................................................................................................................ has permission to perl orm ........ ........ -A...................... wiring in the building q........k ................... ... .......................................................................... . ....... .. ................ ... at ....... ........C-e..................................... cy..A-4z- eh� d ................ ... n over,Mass. Fee.5.5.................Lic.No) ......Z ...O'A..................... ELECTRICAL INSPECTOR • Check# Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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(NEC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice f his or her intention to perform the electrical work described below. Location(Street&Number) e.- Owner or Tenant k f.r1 `Fq r h('11 Telephone No. 7211-7261-O/10 Owner's Address Scrm e- Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building (3avd//n,--5 Utility Authorization No. - Existing Service aC 0 Amps 1e7 35;�Volts Overhead ❑ Undgrd 2— No.of Meters New Service Amps / Volts f Overhead❑ Undgrd ❑ No.of Meters ti Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: cn,msc Srl, Completion ofthe olto in table maybe waived by the Inspector of Wires. 1� No.of Recessed Luminaires No.of Cell: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- El o.o meLighting rnd. rnd. 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. Tons !9,, No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained A-1 p Totals: Detection/Alertin evicesMunicipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of WZres. Estimated Value of Electrical Work: 4-I (51 06 (When required by municipal policy.) Work to Start: c)- i*s 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 V-BOND ❑ OTHER ❑ (Specify:) I certify,itnder the pains and penalties ofperjury,that the information on this application is true anti complete. FIRM NAME: : leC` t-(,C Co. LIC.NO.: 0196 76 q Licensee: Signature "5p LIC.NO.: _ 1 (If applicable,enter "exempt"in the license w ri line.) Bus.Tel.No. bg Address: aoq- 8G d'E'�r ). A"AP19j 1I)' d 1 ,041d Alt.Tel.No.: *Per M.G.L C 147,s.57-61,security work requires Department 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 PERMIT FEE: $ Signature Telephone No. b W yLe 1 .rn►A4 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the • permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, § 32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the -� + notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 1fl Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: r' Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP CTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts : . Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/ilia a�M sy�u Wakkers'Compensation Insurance Affidavit.Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMIITTING AUTHORITY. Please Print Le bl Alicant Information a Name(Business/ftauization4ndividual): Address: 0 6waz t CitylState/Zip: C i Type of project(required): Are you an employer?Check the appropriate box: l.❑I am a employer with and/or part-time).* 7. ❑NeVd6nstr6otion emPto ees(fall 2.1;j am a sole proprietor or partnership and have no employees Working for me in 8. []Remo deluig any capacity.[No workers'comp.insurance required.] 9. Demolition 3.FJ I am a homeowner doing all work myself-[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will I1.❑Electrical rirs ox•additio�rs ensure that all contractors either have workers'compensation insurance or are sole epa proprietors with no employees. Plumbing repairs or additions 5.❑T am a general contracfo>and I have hired the sub-contractors listed on the attached sheet. 13'.[�Ro6f repairs These sub-contractors.have have and have workers'comp.insurance.t 14.Q Other 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•tlus affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this liox must attached an additional sheet showing the name of the sub-contractors and state whether or;not those.entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Yam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date' Policy#or Self-ins.Lie.#: �ov�� �, City/State/Zip: /9- iration date). / Job Site Address: f�/ Attach a copy of the workers'compepsation policy declaration page(showing the policy number and exp Failure to secure coverage as requir ed under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment,as well as civil p be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. X do hereby c under tliepains an—d—penalties of perjury that the information provided above is true and.correct. . ��'-� � �``�" Date• 9'o2�—lJ� Signature: Phone#: Official use only. Do not write in this area,to be completed by city or town offzciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of gealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions 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 in the.service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual-,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiv6f6r trusted of an individual,partnership,association or other legal entity,employing employees..However the owner of a dwelling house having not more than three apartments and who resides therein,or the occiipani of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local Iicensing 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,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the Workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance.•If an LLC or LLP does have employees,a policy is required. Be advised that this.affidavitmay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date'the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant thai must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Fold.I nen#Jetacn mora Att vercra€rns R (3lIlOIVHE/ i.TH OF M ►SSRHUS 'FS i �� �`f�+�1��`{i�01��►`f+°YC�1►1'G`I�'iLllO'1+�►lswl�lil�. l(SSOES' THE -FOLLOWING CRNSE AS ,A t ' G`r 5�'ERE;D MAST A E.L-ECTR-J,C r" :ELE_CTRI C ;CO tm {iA-V ID E:BfDRfl 209;;B6 DtArt RD 3 ;° jr,. -0 172 i�Z4 577 ` ®OAa . �ESAUSETTS @s 441, C I ANSA ISSUES THE F..ULLDW llN L-FC:E*i f ; A RSG 1OURN£YMAN EL-EC3.Rl C t 4l d3AWF#D f ;9EDROSTA A>d �' Z09 130 GR ► itb �v :. ACTONiA 01 7 20 577 xn s . 2P-9 07/1 l 5 C or Set, • -t' v .....I.,�� 1� � Date.14.!.i CF NORT�y,hO TOWN OF NORTH ANDOVER s PERMIT FOR WIRING 88 HU This certifies that ........(......_.. . .................... has permission to perform . :!`"V?�—� .................................................................................... ,wiring in the building of:` . ., .�, at .�......... CSL 1.N•.............................. North Andover,Mass. :P........................................... Fee ZQ '` Lic.No. � .. ... .......... .. ...:�. . r f/..�. ..... ............ ELECTRICAL INSPECTO1V V Check# i b .929 -C-\ Commonwealth of Massachusetts Official Use Only rPermit No. a Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 521 SMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �_/lam City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notihj,or her intention to perform the electrical Work described below._ 1 Location(Street&Number e Owner or Tenant 4 Telephone No.97,P—J.'&p Owner's Address Is this permit in conjunction4LIthi a buildin7/j,rmit? Yes ❑ No00' (Check Appropriate Box) Purpose of Building 1 t� uC� Utility Authorization No. Existing Service Amps / 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 Electrical Work: Completion o the ollowin table ma be waived by the Inspector o 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 ❑ n- El o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiatin Devices Tonnsso.oAlerting Devices No.of Ranges No.of Air Cond. TotalNo. Alin � No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: """.............. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mbmcipal ❑ Other Connection No.of Dryers Heating Appliances KW Security stems: 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 E uivalent ' OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of ec ical Work: ,,p0 (When required by municipal policy.) ? Work to Start: /p s' 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 coy age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 1 certify,under the pat d penaltieso perjury, at the'formation on this application is true and complete. FIRM NAME: ,,y LIC.NO.: Licensee: r,4LJ Signat LIC.NO.:/,,;I (If applicable rater ` mp 'in the4icqftse nutyber line.) Vis.Tel.No.,• 7/� Address: wt►� .►w.�, L � Alt.Tel.No.:�7'"l�STrf— *Per M.G.L c. 147,s. 57-61,security wort requir6s Department of Pub is 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. 1 am the(check one)❑owner ❑owner's a ent. Owner/Agent PERMIT FEE.$�- Signature Telephone No. l�� �Slk3 � e �c� L • 1 { i The Contmma immith of Mask musetts Delaarknent of Industrial Aoddyft = Office of I nwstigations 1 CongressStred Suite 100 Boston, MA 021142017 °'M 5�•V wwwmmassgou/da Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant I nformation Please Print Leqibl Name (Business/Organization/Individual): Address: ar City/State/Zip: Z��,to ®/ Phone#: Z//-771 � Are you an employ ?Ched the appropriatebwc: Typed project(required): 1.❑ .I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.Del am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, []Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.F21flectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who 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-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 lead 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 oerti haler the painsandIdes jury>r W tits information provided ablDW i true and correct Ki mature: ,may Date: Phone#: /4pl 771_ -,11914d Official use only. Do not write in>lhis area,to be oom pleWby dry or tomn offidal. City or Town: Permit/License# I suing Authority(circle one): 1.Board of Health 2 Building Department 3.City/Town Clerk 4.Electrical l nspector 5.Plumbing I nspector &Other Contact Person: Phone#: ++CSMM-ONWF14- `� ,• • mss • . • � At : 'tel C ANS AST4 ri K 3- �� YS To 330 "ti �1 77 3 I r ...-+C`)NfM N1iLTi ` . .. i x - ARW7 - VD V St� a[ti' Y/� - t• � r tN h r i i V10/29/2013 07:05 FAX 781 842 3293 Woodbury Electric Z001 ... 1087 �0E3dB*MSwk1Vbd WN,KEVIN M.WOODBURY eaer.oIMMAMIX t3 CARTMA ER RD, 53-7012-2110 � PAY to T+E 141Lt T ! $ ofMw of +�� BUILDi►4G DEPT /v If ' =WWI law 000&0871' 1:2 1 10 70 12 01: 26 463113 261' • C 555820023365 091809 20131022 000000000264631326 ' RN DEBIT LI.ACASSE 000 •�'RG- o er-Main S 0135 93003 5558 9 0015 North And v �M r F=x r ex i71 ' n ti V Date... ......... 3i; aoL TOWN OF ORTH ANDOVER P�"TFRT WIRING This certifies that ........... . ......6-V....... ................ ........................................ Pv.!.... ..... 6 has permission to rfo ... ........ ...... ......./ ... ...... ....(j .................. wiring in the building I............ ............ ..................................................... at ..........4�...�..ee. ... ............L ......... .................. ...................... ............. North Andover,Mass. 'FePlb...............Lic.N ......... . CAL N.SPEMR...... Check,. 1965 Commonwealth of Massachusetts Permit No. fULM ific al Use Only �l Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M7 C R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Ab 10--2111-2 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice i2or erintent'on to perform the electrical work described below. Location(Street&Numbe N Owner or Tenant ,.iJ ,g i Telephone No. Owner's Address Is this permit in conjuncts ith a build' permit? Yes ❑ No (Check Appropriate Box) Purpose of Building LUtility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters n Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SusNo.of Total p.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA — No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency ig Ing rnd. rnd. 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. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number.I Tons I KW No.of Self-Contained _ Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: D No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: ---- Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications No.Hydromassage Bathtubs No.of Motors Total HP No.of Deviceor Equivalent nt OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Y Estimated Value of lectri al Work: (When required by municipal policy.) Work to Start-16 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 BOND ❑ OTHER ❑ (Specify:) I certify,under the sand penalties o perjury,t at the i rmation on this application is true and complete. /f FIRM NAME: „� LIC.NO.: �/ Licensee: ` Signature IC.NO.: �3 Q (If applicable er emp 'in the 'ce se nu"m}}er line.) el.Ni ? Address: � AQr1 Pr oCcK.-N �pQ� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requir s Department 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 10 required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. �., int Form The Commonwealth of Massachusetts Pr Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 ' Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Kevin M Woodbury Address:32 Carter Rd City/State/Zip:Lynn,Ma. 01904 Phone 4:781-771-4986 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 employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction listed on the attached sheet. 7. F-1Remodeling2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 10. ✓❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Hwneowners who 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-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 lead 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 certify nder the ains and enalties operjury that the information provided above is true and correct. Si nature: J Date 10/28/13 Phone#:781-771-4986 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#: r g ! • • � •�}�w.ate�}}�� y]�� � IKS S'sr1 .Aye �}'�) ff }j��r 'L7 E 4 LOV t c A5EOURtEtAN ESE MA AL d # g s � � �•�„� is tea, �c►� � � -----=�--��', ! • • . . • ESEC'` I C Aus d h; SU EOLLOWjNO LEE AS x R£0 .p MASTER ELEC s oOBBURY 3Lr-AR TER3 F �Skx 4 �ti4� 3-33 7 `i77�7'ITTTRiP�F-T��7• a. � 1 � x '� t - G- t ( 9027 Date.-7 . . . . . . . . . NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUSE� This certifies that . . . i has permission to perform . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . at. . .L( I . . .G.L Q! ✓t. .>! ,r1.rf.t'. . . . . , , . , . , North An over, Mass. Fee3 U�. .Lic. No.. . . . . . . .// . . . . . . . ( ` PLUMBING INSPECTOR Check # `t U 2 f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING h City/Town: _,MA. Dat _ r`./� Permit# Building Location: OT I � L �kiOwners Name Type of Occupancy: Commerci l❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:❑ Replacement:[]� Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED SYSTEMS US Z z O Inv d' z 1- Y } to Q Q to z D N to WfA H z ?� to = �► D� W z O to W Q Z Z H Z U d ,L_ O W 3 W p U. F=- Q to to O W tIf Q Z W w N >- � Q x s = Oa O 3 v Z i Q 0O a z z to t- t- = o to ug a m m c o � _ g g OW 0. N SUB BSMT. BASEMENT 1sTFLOOR 2"D FLOOR 3"D FLOOR $ 4T"FLOOR FLOOR ' 6 FLOOR 1 3 7 FLOOR F-F-H I I 8 FLOOR r, Check One Only Certificate# Installing Company Name: G 9H--oftporation Address City/Town: State:A)I/ Partnership Business Tell jO`� 0-30676 Fax: tQ/!7J ❑Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: � � I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes V'•o❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner s A ent I hereby certify that all of the details and information i have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha ter 142 of the General La By Type of License: Tale ❑Plumber S ature of License umber Master I City/Town ❑Jouman License Number: APPROVED OFFICE USE ONLY) -� Location r v No. `� Date x NORM TOWN OF NORTH ANDOVER 3: •. OL " Certificate of Occupancy $ Building/Frame Permit Fee $ �ACHUs Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 18222 j `—Building Inspe6r J t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING :'I iIS, OS Oi''Q It1A uSC o91 V BUILDING PERMIT NUMBER: DATE ISSUED: _�� S 66C( .SIGNATURE: W4 c( Building Commissioner/I for of Buildings Date SECTION I-SITE INFORMATION Z 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O >b& /� I. . lq& 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 R 'red Provided Re red Provided 1.7 Water Suppty M.G.L.C.40. 34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private f Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I r�erol Record CN Address for Service: 11 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z Signature Telephone I , SF. -_LION 3-CONSTRUCTION SERVICES 3.l Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. O License Number Address D Expiration Date Signature Telephone 1.2 Registered Home Improvement Contractor Not Applicable ❑ ;ompany Name Registration Number rm.. Adress ra W_ Expiration Date ^z i2nature Telephone Y d 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.......0 No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: COP 1��C o abate as SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be rg �'� CI ,ITSIGOIilr om leted by rmit applicant z Y 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X (b) 4 Mechanical HVAC) 5 Fire Protection /�✓ 6 Total (1+2+3+4+5) 1Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ` % A ,as Owner/Authorized Agent of subject property Hereby authorize R6 `'S to act on My be < , all matters relative to rk authorized by this building permit application. .G C �- Z'/- 6�f Si nature o weer 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 7DDAF-NSIONS of Owner/A ent Date TORIES SIZE NT OR SLAB FLOOR TINMERS 1ST ND FD 2 3 ONS OF SILLS OF POSTS DIMENSIONS OF GIRDERS I-SIGHT OFFOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CF-MVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1p FORM - U - LOT RELEASE FORM °"-` S rk CP 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�� PHONE - ASSESSORS MAP NUMBER�UO LOTNUMBER SUBDIVISION LOT NUMBER STREET � l I Ce-AAV—AAY)E- STREET NUMBER ................................................................. .......... OFFICIAL USE ONLY RF,COMNIENDATIONS OF TOWN AGENTS / DATE APPROVED 4,22 200C-> CO SERVATION AD STRATOR DATE REJECTED coMMEN�Is6 /00' DATE APPROVED TOWN PLANNER DATE REJECTED COMNIENTS DATE APPROVED FOOD INSPECTO TH DATE REJECTED DATE APPROVED S TIC INSPECTOR- LC 'J DATE REJECTED COMMENTs rcuJ u r J", PUBLIC W S—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTNfENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE VJ/LO/Uv rx1 1J.JJ rAA 151 835 5125 CARLSON WOBURN 1pjUu:f_ i c r • '� -R7 R'' ' z1cT/ONS GN }x o m (� c.s -,c 3a Q, t SPt•rf /�L' 35'f T) - 0 o ��. till V F2otitT;64r--(loo' 9 ` 3 3 � i Pik g e C 's nna Marne sr�m Mort o. In c, aro+►+ao MORTGAGENOR�NC°q DN OVER nmx Rewwto mm LOCATED IN PLA N N O R T H A N n n v r n I/S-1,3Q L.-!?T Co .106t5Q1-4 J. ILol I PT 10 1 G r Gla M Co �r A r� � 1✓;M� �Z l' �1 L,v N sT V4ORTH To of �.. t over �O T Z0 was O - •LAKE dower, Mass., COCHICHEWICK V 7,9 A0 ATED PPS\ Cl `S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT Z6..4)A)..A BUILDING INSPECTOR .............................................................. Foundation �S 3 y/ Cr o�&r L�ti has permission to erect.................�......�........ buildings on ........................ ................................................................... Rough G rr�►� ��� #^ rl, r �r�t0 be Occupied aS ~ Chimney .......A6..&.Y.* .... ... .................................................................................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relatin to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 1,06A I7 & PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ... .., ..... ............................ .. ... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Date....�.'w...��..'.."'O�� TOWN OF NORTH ANDOVER 9,00 PERMIT FOR WIRING �,SSACMUSE� This certifies that ........ � .!���G� ......1..'v z.:6�.! .......................... has permission to perform .......:: tea' � !.�frj.. ................... wiring in the building of....... <!.! ...... 1.. ........................... g�ll at........qJ..C� q..... ................. .North Andover,Mass. t Fee...y���r"�'Lic.No.e;. 7.::.1.9.... ... .1.�'. . ELECTRICAL INSPECMR y Check # 58 '16 Commonwealth of Massachuset Official Use Only Permit No. I-?l 6 Department of Fire Servic 5L�.5 ® cs Occupancy and Fee Checked BOARD OF FIRE PREVENTION RE LATIONS [Rev. 11/99] leave blank APPLICATION FOR PERMIT O PERFORM ELECTRICAL WORK All work to be performed in accordance with a Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMA ION) Date: )N�, Z ZUS� City or Town of: To the Inspector of Wires: By this application the undersigned gives notice f his er intention to perform the electrical work described below. Location(Street&Number) U 0 Owner or Tenant 30tolf, �k k Telephone No.crg 50Z f Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building VC." 4 %s agaai 1, Utility Authorization No. Existing Service I Oy Amps t-Lo/2_.4r-->VoltsOverhead❑ 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: Completion o the folloitin table m ay be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets ( No.of Hot Tubs Generators KVA - No.of Lighting Fixtures Swimming Pool rnd.Above ❑ nrnd. E] No.of Emergency iging Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.o Self-Contained Totals: I I 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 Equivalent No.of Water KW o.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: Attach additional detail if desired,or as required by the Inspector of Wires. 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 'c-" BOND ❑ OTHER ❑ (Specify:) $ , I(o -ZOOS Jf op (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: -2-- D S Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. 1 FIRM NAME: ",`t2 ii� < C, LIC.NO.: o`,,cc11 t-/-'14 Licensee: t '�k ilk Signature LIC.NO.: 7-00+7 - A (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.;W3 30-5 833 8 Address: 3-Z \0ASOU QA 14\��soy Alt.Tel.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 a ent. j� Owner/Agent Signature Telephone No. PERMIT FEE: $ s;� Commonwealth of Massachusetts Official Use Only cnmmw� Department of Fire Services Permit No.—3 !6 Occupancy and Fee Checked . BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 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:-iy,3!� Z Z(90SJ City or Town of: O- _ To the Inspector:of Wires: By this application the undersigned gives notice of his ocher intention to perform the electrical work described below. Location(Street&Number) 4 �� � UN 4-:m,. w Owner or Tenant o'NN ft_Wk -,Telephone No �.'do r R3 Owner's Address SAM a Li Is this permit'in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building coo (4�bml£ lQ , Utility Authorization No., y Existing Service t DAmps t'Lv/2-4o Volts -Overhead❑ Undgrd❑ No.of Meters New Service • Amps / Volts 'Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefiolloiting table may be waived by the Ins ector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans o ot Trr ansformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ n- ❑ o.o mergency tg mg grind. grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.-of etection an Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: I I Detection/Alerting Devices -" No.of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.o Water KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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. -.1 CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify)S eci $ , 11, •L©o.S .0 Op (Expiration Date) Estimated Value of Electrical Work: W (When required by municipal policy.) Work to Start: L-2-, O S Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains and penalties of perjury,that the information on this application is true and complete. 1 FIRM NAME: A\ 2I k �,., LIC.NO.: Q 4-�/-R Licensee: ti " `VL„ Signature LIC.NO.: Z O 0+7- A (If applicable, enter "exempt"in the license number line.) Bus.Tel.No-;W 3 30S 933 Address: 3Z, VO ASOM( Q A "\��spfq " P33n6 1 Alt.Tel.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 a ent. Owner/Agent Signature Telephone No. FPERMIT FEE: $ s � c i oe�G HOC D ` • '�_ o> ` 12 r' el a Luo sr��✓s;x4 7-a S jai..�-t �t 10 ftP4.,VCC- c 61S s I"-':d-