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HomeMy WebLinkAboutMiscellaneous - 48 BEACON HILL BOULEVARD 4/30/2018 (2) 48 BEACON HILL BLVD 2101058.A-0022-0000.0 41 Datel....1'Z........... NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 7SgACHU This certifies that ......... ........ .......... ..... . .................................................. has permission to perform I>................�Av'..%.Oqxv................................... wiring in the building of...... ........2--0"'4.......................... at ............... ......North Andover,Mass. C, Pol Q Fee.:��2.. .... .... .. Lic.No.............. ...........1 ...... ...... ...... ELECTRICAL INSPECTOR Check # 7155 Commonwealth of Massachusetts Official Use only Department f Permit No. /135 �artm of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leaveblanic) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC),III CZAR 12.00 (PLEASE PRINT IN INK OR TY,,� ALL 1 FO ATION) Da Z 0 City or Town of: ZL To the Insp ctor of Wires: By this application the undersigned gives notice his or her intention to perform the electrical work described below. Location(Street&Number) qff +t�!�CJl, �I L! c� i/ Owner or Tenant A45 /a-yt Telephone No- Owner's Address s IW4 Is this permit in conjunction with a buildin perm1t? Yes ❑ NoLEZ (Check Appropriate Box) Purpose of Building Oji V1 P ly Utilit Authorization No. I R7Vk,G Existing Service ((y Amps 110/ t) Volts Overhead Undgrd ❑ No.of-Meters / New Service Z06 Amps IZD / UO Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity u Location and Nature of Proposed Electrical Work: U��/7,0 c ✓Lul CZo 1a ?ii AM e Completion o the following table map be waived by the Inspector of 6Vires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KV A No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- 1:1 o.o EmergencyLighting rnd. rnd. Batter Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No_of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons 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❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water ICW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No..Hydromass age,Bathtubs No:of Motors Total HP . Telecommunications Wiring: No.ot•Devices or Equivalent OTHER: Attach additional detail ifdesired,or as required by the Inspector of kVires. Estimated Value of E ech cal Work: (When required by municipal policy.) Work to Start: 41Z Inspections to be requested ul accordance with MEC Rule 10,and upon completion. INSURANCE CO E G : Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins xrance including"completed operation"coverage or its substantial equivalent- The undersigned certifies that such cover e is in force,and has exhibited proof of sa e to thJe ermit i5/s u/yng off,C CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �i4ve/lam !//��/�/Q7 /641 �ZI3i10-2 I cer•ti under the i anti en ties o er ur tl t the ' rm«tiort on this application is h hektrzd com Tete. _ fy, P fP J y, PP P FIRM NAME: U�Q�Q �(� /( t� LIC.NO.: 3 Licensee: �S-7opItk �V}� Signature � LIC.NO.: (If applicable,eLV—v 'exe(�/p1tL/�i d license rrtnnber)it e.) Bus.Tel.No. Address: �S K j1 rl^ !� Alt.Tel.No.: *Security System Contractor License re iced 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)Elowner ❑ owner's agent. Owner/Agent Signature Telephone No. PERNJJTT FEE: $ r6 7 Generators Residential& c)each additional meter..$10.00 TOWN OF ANDOVER Commercial: Sewer Ejection Pump: $25.00 ELECTRICAL PERMIT FEES a)including photovoltaic&~ Signs: $25.00 each ballast (Effective March 12 2003) generating Equip Per KVA $1.00 Smoke&Heat Detectors& MIhA1IU ' IrRtV�IV EX-5 b)un-interruptible power systems, Initiating Devices: RESIDENTiL� $2S OU per KVA$1.00 Residential: $1.00 each CoMME1t'CIAL $SO 00 c)batteries over 100 amp.hours,per Commercial: $60.00 up to 10 O SL. CABLE ONT cell $1.00 devices over 10 -$1.00 each OUTSIDE OF .BUILDING Heat Devices: $1.00 each Space Heaters: Air Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each Alarm Systems Security: (for fire Hydro-Massage Bathtubs/Hot Sub-Panel: $25.00 systems see smoke/heat detectors) Tubs: $20.00 each Swimming Pools: Residential: $40.00 Lighting Fixtures 51.00 each Residential: Commercial:up to 10 Devices Lighting Outlets: $1.00 each Above Ground: $25.00 $60.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 $1.00 each $20 each Commercial Pool: $100.00 Carnival Equipment: $50.00 each Motors: (per hp or fractional part Switches: $1.00 each Ceiling Fans: $1.00 each thereof) $2.00 Temporary Service: Oil/Gas Burners: Nlust have Utility Auth(fl'lYatlon 9URil)e7 Commercial New Construction or n�eResidential $25.00 Alterations: Rsidential$20.00 each $100.00 per 1,000 Sq. Ft.of Commercial$20.00 each Commercial $100.00 Construction Space Office Furnishings: per circuit$10 Transformers: Commercial Service Change/ (Relocatable Partitions/Cubicles) a)capacitors,Per KVA $1.00 Repair: Outlets &Fixture: $1.00 each b)ducts,conduit&conductors -� lost have Utility (Associated w/Padmount Transformers)$25 L Authorization Number Ovens Built in/Counter Top Units: $100 (first 100 amperes or fraction,one $10.00 each c)each manhole 0 meter) Panel Change/Circuit Breaker: d)each handhold$5.0 00 1.00 a) each additional 100 amperes Residential: $20.00 e)per KVA$ capacity or fraction. $30.00 Commercial: $25.00 fl primary feeders,$ each(over b)each additional meter$25.00 Phone Jacks: See 600 volts,non-utility owned) g)vaults and equip. $25.00 each Commercial Temporary Service: data/telecommunications Washers: $15.00 each $100.00 Ranges $15.00 each ik'Just have Utility Autborizallon number Receptacle Outlets:$1.00 each Waste Disposals: $5.00 each Cormier tial Repair and/or Water Heaters: $30.00 each Recessed Fixtures:$1.00 each Maintenance Permit: (Blanket Re-inspection Fee: $25.00 Permit)up to 2 Electricians$150.00 'For Multi-Family per air of Electricians over 2$50.00 Repair to Service Residential: ., $20.00 large Commercial Project Data/Telecommunication: Residential New Construction Residential: $1.00 per port yet ��.arillg Itl� ecti0r for (Dwelling): $220.00 Commercial: $30.00 up to 10 pricing: ' (with service up to 200 amps) ,, �+y devices over. 10=$1.00 each Must have Utility Authorization dumber 'Paul 1<�eunedy(978) 623-h_s€lo Dishwashers&Disposals: for services over 200 amps see below (Office Flours S ant to 1.0 ani) $5.00 Each a) for each 100 amps capacity or Dryers. $15.00 Each fraction add$20.00 3; Emergency Lighting(Battery Units) b) each additional meter$10.00tlgpeet.>«IIelterllt#_��> $ 1.00 each unit c) each additional pan6sub panel I ROUGH Feeders or Sub-feeders: $25.00 I FINAL each 100 amp capacity of fraction Residential Additions/Alterations: I TRENCH (if applicable) thereof Residential: $5.00 each $220.00 maximum Commercial: $15.00 each Residential Service Change or ADDITIONAL Gas/Oil Burners: Underground Service: INSPECTIONS *S25.06 (if $40.00 Residential: $20.00 each Nfust have Utility Authorization Numberapplicable) Commercial$20.00 each a)one meter,up to 100 amp capacity $40.00 (revised 07/05) b)each additional 100 amp capacity or fraction$20.00 Date.... .. ..... ....... ... .... NORTh TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHUS Et This certifies that ....................... ................ . .............................. has permission to perform .............. Agz"'....................... wiring in the building of........kb....AAEA .................................... at..qg:'A ///4.C.... North Andover,Mass. Fee..'/�............. Lic. .......................... No.1217?—A...... .. ELECTRICAL IINSPECTORCheck I 960T 7082 Commonwealth of Massachusetts official Use Only SEEM Department of Fire Services Permit No. D F2- / Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS pzm 9/051 eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12. (PLEASE PRINT W INK OR T�YP�ALL INFORMATIOA9 Date: y. //"0 to City or Town of: IV!° AO D Q V U-IL To the Inspector of Wires: By this application the undersigned gives notice of his or her intenti/ons to/p/erform the electrical work described below, Location(Street&Number) Y aC //oJU H i S iy b Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Rusting Service Amps / Volts OverheadEll 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: WI RG T/ V lJ m p Completion of thefbUowin table may be waived by the 1 ar of cores. No.of Recessed Luminaires No.of Cert.-Susp.(Paddle)Fans °'° Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [] ❑in- o.o Emergency g & d. Battery Units No.of Receptacle Outlets a No.of Oil Burners FIRE ALARMS N_o.of Zones No.of Switches No.of Gas Burners o.oT Detection an Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pump er ons o.o Self-Contained Totals:I Detection/Alerting Devices Munical No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW ecNo. ems:* r'Y No.of Devices or Equivalent o.o ater IOW No-.-Of _ _ o.of Data Waring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs of Motors, Total HP ernmmnnvices or Wiring: No.of Devices or Equivalent f OTHER: 1 1./ O o Attach additional detail if desired,or as required by the Inspector of 91res. Estimated Value of Electrical Work: (When�+Qa (When required by municipal policy.) Work to Start: 12-1111 ()(2 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 coypee is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the acts andp nalties ofperjury,that the information on this application is true and completes FIRM NAME f: T �T E J..1/V(y L�C G("�L l C R /"e LIC.NO.dw Z Licensee: Vhi1 t'A �q/vN� z,� Signature LIC.IY0.:3�L/,fd 67 (If applicable,enter"exempt"in the license number line.) ,� Bus:Tel.No.:9 -$3--5'3-9j' Address: 1 I U rTAZl�SU►� SF-1-c/1/t ��t'IVe rv, x'14 018V1-1 Alt.Tel.No.:97,f-,6—,1f-7/f *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 PERMIT FEE: $ Sienature _Teleohone No. .1 M Location No. Date NOR71y TOWN OF NORTH ANDOVER - ?0.- .S° Opyo s I O � 9 ' Certificate of Occupancy $ ;•�i++no•tt� Building/Frame Permit Fee $ (,J 4CMUs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 245:x;* Building Inspector i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: - Date Received ' Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 2 Gl C.i� N I J3 Jd• f J �Yl d V�: n 7 b 1� 44 S Print PROPERTY OWNER ThCM a.S a4n� b"(CAA t 0 1�kG CL+n Unit# Print MAP NO: PARCEL: 2 BONING DISTRICT: Historic District yes o Machine Shop Village yes 100 year-old structure yes n�o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Ca-One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑Floodplain ❑ Wetlands ❑ Watershed District 11 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: t2e�c,i r w rU1aC-e__ int (Identification Please Type or Print Clearly) (n I 3&S 0 o i-Cl Cry(n:e OWNER: Name: Th o rvt Q S o,.n CQ (J Q_Ai' U e 0 LJ-Q a*2 Phone: S-1 S e)7- -14C'1&2 C 7)t Address: 4$ BCacAv� Nifl t31�d Vie . (vncfover, rmfl w8,,45 CONTRACTOR Name: SeA T Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ osi`(YICL a V So o FEE: $ 3Q I C4'eVioo! Check No.: S_ v Receipt No.: aq. " S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 4�ignature.of Agent/OwnerL_�_ � Signature of contractor Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ StampedK Plans ❑ TYPE OF SEWERAGE DISPOSAL �! } Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed onc h Si nature I � COMMENTS &j HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway'Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT)-CTemp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 Jun&mi µORTfi TOWN OF NORTH ANDOVER Of�ttao 6'S,t, 3� °L OFFICE OF z BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2=36 North Andover,Massachusetts 01845 SacHus� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERNUT APPLICATION Please print DATE: JOB LOCATION: 4Z be-a-COV, 01/u ry►r9 Number Street Address Map/Lot 111od� � "}81-So�- y�r6Z HOMEOWNER'(l-i o t A a S ()o N C lz D uci a.v\ 1�_eR c� o03�r Name Home Phone Work Phone PRESENT MAILING ADDRESS `fig 0.-o vq R41 Mod ISO . (Y)(f bi�LfS" City Town Stare Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to 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 HOMEOWNER Person(s)who gwns 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 structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances 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 North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 AREA = 15,948 ± J J >- Gar. C cli tn � lerij :,3 S N F L L N U T O _ 20.0 _, VPizop 01 Ho. 48 A �-... I7'of-.. DD• �I ul � 38 A�l G o 0 PLAN G"OWING LAND OF DANTE IPPOLITO -j"OfMA W 0 12TANDOVE(2, MASS ,I�-�( CHARLES N SCALE-� 'w 'ZO' C. JUNE 19G3 o MARTIN ti Br1AS9FuR Assoc 'TES•60� BAILEY ST 1<iAvER1-tiLL� MASS. "p Co �14re"4o* hp_su N c NoRTW ANDOVER BOARD OF APPEALS iNG Pr2o E�' � DAA O 14EARING DAT$ 0 ApPQOVAL ORTM TO" of And VIA No. p A LAK- _�� o dover, IVMass., Co HIC HE WICK �d A�RAT E O `�C S U BOARD OF HEALTH PERM IT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.........................�....: . L ! ,GGS............�.. !n......... ............. "" .............................. Foundation has permission to erect.........:..........................buildings on ........ .8......�-�.kGc!!!�... .. Rough ---�'"� to be occupied as............. ......... ...���......��.�'�........s.T�� ........................................................:......... Chimney .. provided that the person accepting this permit shall in every respect confor to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 3D % PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIO TS Rough INSPECTOR Rough =======...... ............ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough ,. Display in- a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. 1 • 1` ,J The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl� Name(Business/Organization/Individual): I_V1 D 1A a S aA)d G,N 1 C �- L(q aA Address: 4W 13e.QCZY1 Wtt (3VA. City/State/Zip: �Ja . A--n CkO-J 6rl M ft 01&445 Phone#: D ate,iy tt ton-a- 007-5 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 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# 7. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. 9 YE]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.[_1 Electrical repairs or additions required.] officers have exercised their 3.R I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[Z Other r parr 1 rcP lace -S 0 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 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 their workers'comp.policy information. 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.Lie.M 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Si ature: &Lte Date: Phone#: /? 3(ps 0079 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#: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �� F2, Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev.9/05] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.0 {PLEASE PRINT IN INK OR qPf ALL INFORMA77019 Date: City or Town of: l IV, AO D W I✓� 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) �- � c, p,\I Ali tl/ S W D Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility.Authorization No. Existing Service Amps / Volts OverheadEll Undgrd❑ No.of Meters dgrd❑ No.of Meters Ti c 0 11 (2 f o� Date. . . ........ An table ma beuwivedbytheLrueectorof Vires. NORTH O.Q Tota c� 4ti Transformers ItVA �.oo TOWN OF. NORTH ANDOVER 3 c Generators --- KVA PERMIT FOR WIRING ► o.o mergencY Lighting • + Batte units sAcHu FIRE ALARMS No.of Zones o.o etection an a Initiatine Devices This certifies that /.. 414-e.... . ............... . 6 .............,/� .... No.of Alerting Devices has permission to perform .............. / f .... ! /. ..... 0.0 e - ontamed DetectiontAlerting Devices � lU wiring to the budding of.........Z.V...... .................. Local❑ umecti ❑ Other /, • •••••` Connection at.. .. ... C7 . North Andover,,Mass. Security Systems:* ��'``F'''.. • •!`.�'... � ...A. -*��'. No.of Devices or E uivalent Fee.. ... ..... .LIc.Nol2./.7?4... .... � .,: . De' Data ' ELECTRICAL INSPECrTOR r 1 No.of vices or Equivalent U e ernmmunicationsirmgg: Check .# 6O L uNo.of Devices or ivalent desired or as required by the Inspector of Hires. r a, ipal policy.) Work to Start 2. 'y f V 6 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 cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 71 BOND ❑ OTHER ❑ (Specify:) I certify,under the sins and p naldes ofperjury,that the information on this application is true and complete. FIRM NAME: �sE 1^I IV ty E L-C L�4ti t G F►� �'"�- LIC.NO.: 'I��Z A Licensee: i i P �t.}�VN� 2.-Z— Signature LIC NO.:3J/1/fil F (Iapplicable,enter"exempt"in,the license number line.) Tel.No.: 1 Address: 1 U rT�ZI�S(I►� SY-4 rAA tiUAl t7V't tv., N4 0l6Y��/ Alt.Tet.No.:97,f7/,!y *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 PERMIT FEE: S Signature _Televhone No. t-unimoniveaun of Massachusetts me Useonl Department of Fire Se>tces — [o7: it No. �_ BOARD OF FIRE PREVENTION REGULATIONS pancy and Fee Checked APPLICATIQ1� FOR PERMIT !, /OSJ leave blank �' All work to be performed in accordance with the Massachusetts setts PERFORMElectric ���Q������, WORK �ri B� (PLEA SE PRINT IN,�OR TYP ALL INFO / t�M �),527 cN1R 12.0 City or Town of: �R- Date:—� �� By this application the undersigned gives notice of_his:or:her intention to 3erfo tthTo the e�P C tor-k described bel ow Location(Street&Number Owner or Tenant Owner's Address _ Telephoneay.,. Is this permit in conjunction with a building permit? �— Purpose of Building E J Box) E?dsting Service G'�- I Amps / volts j C� HORrH 1 TOW ectoro Aires. o G�� A (Vfo les ana- This certifies fhtr' �- yi y ( �itiatin Devices �.of Alerting Devices has permiss' v.oSelf-Contam Detecdon/AIertin Devices wiring. - unicipa f Local Connection ❑ Other ecuntpSysS s:* r No.of Devices or E uivalent ........... Data Wiring: No.of Devices or Equivalent . ��Q ..."Telecommunications� irin Check - No.of Devices or E uivalent 7082 ;'desired,or as required by the Inspector of hires. opal policy.) Work to Start: 2-1 y/ ,be requested in accordance with MEC Rule 10,and upon completion- INSURANCE ompletion_INSURANCE COVERAGI,, d by the owner,no permit for the performance of electrical work may issue unless the tic zsee provides proof of h4 mance including"completed operation"coverage or its substantial equivalent. The undersigried certifies that such cor oe is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE-X.;L� ND ❑ OTHER ❑ (Specify:) I certify,under the sins and s 0penury,that the information on this application is true and complete EIRM NAME: 9T AT 6 ),i-I14r I ::X7/'VL LIC.NO.: Llceee* �► i'Aq<+//" ]_Z r SignatureIL LIC.NQ.:3*/fU F (lfgable e-Mr~ "int a license number line) Bus:Tel.No.: Address: I N 0 �`�L�S7f►^ S -�r�A t G j wl USP av, )'(� fil f cl y�/ Alt.Tel.No.:!Z2t-;'?,!1"-7/s Y S Coc=actor License regiured for ties work;if applicable,enter the license number here: O RAS fir; CE Wp�ER: I ani aware that the licensee does not have the liability insurance coverage normally ;mired by law. ]3y my signature below,I hereby waive this requirement. 1 am the(check one) IT FE owner's agent. Oi`ner/A ent PERMIT FEE: $ Signature _Telephone No. -� Coolmonivealth o,f Massachusetts olf aifl Use Only -�......,_.� Department o,f Fire,services Permit No. f BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ APPLICATION FOR pER11lIrT T ppED tee`' grosj leave blank All work to be performed in accordance with the Massachusetts (MECTRICA �/��� (PLEASE PRINT FN WK OR TYP �, CMR 12.0 City or Town of: . ectol ALL Date:_ f Z- Krw, By this application the undersigned gives notice of his or=hevintention to'perform t_he el�t -�P u nbed below. Location(Street&Number) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes Purpose of Building No (Check Appropriate Box) Eldsting Service Amps Utility Authorization No. � Volts overhead❑`I Undgrd❑ No.of Meters .� ? A ��n ` v 7ndgrd❑ No.of Meters Date. / S © 7/c ... NORTH table In be waived b the I �'_� ector o HIres. 0.0 oe;` r °off TOWN OF NORTH ANDOVER TransformersA PERMIT .FOR WIRING Generators KVA o.o +mergencyig rung' Batte Units Ss�cHusa` FIRE ALARMS No.of Zones o.o etechon an Phis certifies That ............«✓ !i Inftiatin Devices .- . No.of Alerting Den 'ccs has permission to perform .............. o,o e - ontam� "—` <* wiringin:the building of........ -ff.. � i. � .......... . aDevices Detection/ I°� Connection at..l `.1.�1.��^ 4`..!?.� �.... rF'/^' ecu itySystems�'_ D Other North Andover,Mass No.of evices or Equivalent ` - � 172- ..........l..,LECTR �r ICAL INSPEFTOR ? {1, Data Wiring: Fee..r7. ...... ......... Lic.No.............. Ef. . ....•..�........ .,..:.,.... No.of Devices or Equivalent r Telecommunications w ngg: Check gC No.of Devices or E uivalent 7082 desired,or as required by the Inspector of f3 ims. ;cipal policy.) Work to Start: ` 2—/Y/()6 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 license°provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The unda-sigsed certifies that such cov ge is in force,and has exhibited proof of same to the permit issuing office. . CHECK ONT: INSURANCE r BOND ❑ OTHER ❑ (Specify:) I cert),under tht ages and p alder of perjury,that the information on this application is true and complete. FIRMI -,ME: e P�Ti* l-IfV L: LIC.NO.:,1 I?_ Licensee: + p -,q ?I-? Signature LIC,NO.:3 J//,fl! af } . " — a 11 number line.) . . e' s S 9a ble eerpt rlt a , / L sa � Suva 5T`-f-0A . . ry , �C�-actor License requiredor this work;fu`applicable,enter the license number here; ty S Oy L, + L»; ANCF,VVAIVEF- I am aware that the Li see does not have the liability insurance coverage normally ;wired by la r. By my signature below,I hemby waive this requirement 1 am the(check one) owner ❑owner's agent_ Qvimer/Agent o. PERMIT FEE: S Signature _Televhone N