HomeMy WebLinkAboutMiscellaneous - 52 ESSEX STREET 4/30/2018 52 ESSEX STREET
210/103.0-0044-0000.0
- 2012 Massachusetts EIectricaI Code Amendments 527 CMR 12.00§Rule 8: In accordance with theprovisioas 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.GI c. 1.66,§32,an
electrical permit shall he 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 shalLbelimited as to the time of ongoing construction.activity,and maybe.deemedby-the7nspector-of_Wires abandoned-and.invalid_ifhe
1 or she has determined that the aufhorized world 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 promoteiob;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 concerning 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 qual-ifying period beginning on August 15,2008_and extendingthrough August 15,2012.
Rule 8—Permit/Date Closed: ��-`j�/ * *Note:Reapply for neve permit
0 Permit Extension Act—Permit/Date Closed: ��—
a
00 � � �� //
Date..... ... ......
NORTH
°f' •1"° TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SSACMUS�
This certifies that ��� ,� [ ..®.
................................. ..........:. .......................................
has permission to perform ......... ! �� � .......................
...... ..............
wiring in the building of................ .. ���/J�y`r
.........................................
r
at..:J...Z..........5���,.�J........q. ...........E.ZC72CAL
O
rth Adover,Mass.
Fee... 9Q..g�Lic. ............ .. .... ..ORE
`
Check #
r
Commonwealth of Massachu- official use only
segs Permit No. Moo S^
Depalrhnent of Fire Services Occupancy and Fee checked
BOARD OF FIRE PREVENTION Rev. 11071 (leave blank)
REGULATIONS
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASEPRINTININKOR TYPE INFORMATION) Date: Cly, ._-,1 270
City or Town oTo 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) rj V
Owner or Tenant: Telephone No.&0,2)
Owner's Address:
Is this permit in conjunction with a banding permit? Yee ❑ No X (Check Appropriate Boa)
Purpose of Building: Utility Authorization No,
Existing Service2 0 0 Amps 2-tJ 0 j J&D Volts Overhead V] Undgrd❑ No.of Meters
New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
e Location and Nature of Proposed Electrical Work: g000mater eeteide tl�Il C C f )za+A-c
Colesion othe ouow[rr table me!y be wxrived by the Itrs cwr of tires.
No.of Recessed Luminaries No.of CeiL-Susp.(Paddle)Fane o.of Total
Transformers KVA
No.of Luminaries Outlets No.of Hot Tubs Generators KVA
No.of Luminaries Swimming Pool
Above n- II---II o.o mergency g
nd. ❑ d. 1—I Battery Unita
No.of Receptacle Outlets No.of On Burners FIRE ALARMS I No.of Zones
No,of Snitches No.of Gas Burners o.57 Detection an
InitiatInZ Devices
Total
No.of Ranges No.of Air Cond. Tons Na.of Alerting Devices
No.of Waste Disposers eat Pump rqumber one W No.o ontaine
Totals: - I"--r.....—. Detection/Alertin Devices
Municipal
No.of Dishwashers SpacefArea Heating KW Local Connection ❑Other
No.of Dryers Heating Appliances KW SecuritySystems: 61
No.of Devices or Equivalent
o.-07 W atero.o o.o Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications
No.of Devices or Equivalent
OTHER:
Attach additions-I derail[ desired,oras mquiredby the inspector 7 Wires.
Estimated Value of Electrical Work: $ 2Q Z0 0 (When required by municipal policy.)
Work to Start: Inspections to requested in accordance with MEC Rule 10,and upon completiorL
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:) Netherlands Ins.Co. 3-25-10
I ceWfy,seeder the pants acrd penaldes of perjury,that the infortte .On on this 7app!1!k!a!5d�(-r'ue and complete.
FIRM NAME: Cranny Electric Co.,Inc. LIC.NO.: At 1918
Licensee: Brian ranney gnature LIC.NO.: E25704
(If applicable,enter"exempt"in the license member litre.) Bus.Tel.No.: 1-978-750-6900
Address: 10 Rainbow Terr.,Danvers,MA 01923 Alt.Tel.No.:
MAR/31/2011/THU 01 : 42 PM FAX No, P. 001
The Commonwealth of Massachusetts
Department of.i"ndustrial Accidents
Office oflizvestigations
UV . 600 Washington Street
Boston,MA 0211.1
www.mass.govklia
Workers' Compensation Insurance Affidavit:Builders/Colatractors/Electricians/Plumrbers
A,pplicant Information Please Print 1& ibl
Name(Business/OrganizitiorAndividual): 77(r)J�
Address: /UQ(A' J,�t,J Terrace-
City/State,/Zip: 66h✓C{f ' 14A' Phone.#: 7g. 7 _O �o G
Are ort an employer? Check the appropriate box;
1.WI am a employer with G D 4. [] I am a general contractor and I Type of protect(required):
employees(full and/or part time).
* have hired the sub-contractors 6, Q New construction
2.❑ I am a sole proprietor or partner- listed on,the attached sheet, 7. []Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
j working for me in any capacity, employees and have workers' 9. Buildin addition
[No workers' comp. insurance comp, insuran.ae,#• g
i required.] 5, ❑ We are-a-corporation and its 10-El Electrical 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 bF exemption per MOI
12.Q Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13,0 Other
employees, [No workors'
comp.insurance required]
*Aay applicant that checks box fl nwa also fill out the section below showing their workers'compensation policy informarion,
t Homeowners who aubm4 this affdavic indicating they are doing all work.and then hire outside conttaetors MUSE submit a new ekidavit indicating such,
tComraccors rbat check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not chose entities havo
employees. If the sub-contactors have employees,they must provide their workers'comp.policy number,
r ant an employer that is providing workers'compensation insurance for my employees. Balow is the policy and job site.
information, rr
Insurance Company Name: / 1'��e1r Qui �o
Policy#or Sclf-ins,Lic.#: (/1�C ��D �7 Expiration Date: '3 a
Job Site Address: City/State/Zip:
Attach R 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 penalries of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa,STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DLA for insurance coverage verification
•1"do hereby certtfy under lite pains•andpe{zattics ofperjury that the information provided above is true and correct
e: G1.2tiL 'Dater
phone#: g 07_
FOther
e only. Do not write in this area, 0 be completed by city err town official
wn: Permit/License f#
thority(circle one);
f Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
rson: phone M.
Date.
ha TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
,SSACHUSEt
This certifies that . . . . r � 4..� , . . ��! ... . . . . . . . . . . . . . .
has permission to perform . . . : f. . .�:`�`� 1. � -. . . . . . . . .
plumbing in the buildings of . .
at. V .5.) :�.y_. . . . . . . . . . . . ., Nort Andove .Mass.
Fee p�0,b(. .Lie. No./�.6,. . . . . . .!' .. . . . . . .
PLUMBING INSPECTOR
Check
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING.
City/Town:. . ,A11C]n Y'L� , MA. Date: Permit#
Building Location: r'DZ Owners Name: �aLkl ,&6(41(16% ;
Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ]
jr
New:❑ AlterationO Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑
FIXTURES
4 z
z
N o
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U) a z z y _m Q Q W . z
q rn x M M a W 0 1- w z y Y m � - Q X
lY O M 0 to e a a z >- o a9 z w m z a ,
G LL Q fn W 0 la W N J —! tY EL' tY
a Y x $ O ° F 3 a z Q LL a Y a = w W w
a s ° a o F ° > ° ° ° z z a a a
a m m v o LL ° x Y o°G (av 5 o
SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
Sim FLOOR
6 FLOOR
7 FLOOR
8 FLOOR
Check One Only Certificate
Installing Company Name:
'F� ��!
[I Corporation
Address:!;_1_]��i< Cityfrown: 1.X?.Q�(��� State:
❑Partnership
Business Tel: 116 -7rpQ (C9 0D Fax:q-IS 1-77 3z c� P Firm/Company
Name of Licensed Plumber: �QV-MoO ' Nt
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Ye�6 No❑
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
Signature of Owner or Owner's Agent Owner [-] Agent F-1
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 win.be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: �,L.
Title lumber nature i e.nse7
lur�m33ber
Cityrrown [-3- aster License Number: - �(�l
APPROVED OFFICE USE ONLY) ❑iourneyman ��
MAR/31/20111H 01 : 42 PM FAX No, P, 001
The Commonwealth of Massachusetts
D 12 Department of.1ndustrialAccidents
Of)7ce of Investigations
kvi . 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print & fbl
Warne (Business/Organization/Individual): mrj}7e�lll
Address: e-
City/State/Zip: 60 h✓c°{'l PhoneF- 70 6o �6 6
Are ou an employer? Check the appropriate box: Type of project(required):
1. I am a employer with G U 4. n I atm a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6, Now construction
2.[] I 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' 9. ❑Building addition
[No workers' comp. insurance comp, insurarl.60
required.) 5, We area-corporation and its 10.[]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11-[1 plumbing repairs or additions
myself, [No workers'comp. right Of exemption per MOI, 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑Other
employees. [No workors'
comp.insurance required]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information,
t Homeowners who subs*thin affidavit indicating they are doing all work and then hire outaide contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors end state whether or not those entities havo
cmplayeee. If the sub-contractors have emplayee9,they must provide their workers'comp.pollcy number.
X ant an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site.
Information,
Insurance Company Name: /V ! t�7 el Qdl �o
Policy#or Self-ins, Lic.#: LA)C. '3�O q-7 Z�cl 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 DLA for insurance coverage verification.
-I do hereby cert under theme pyahts-and penalties ofperjury that the information provided above is true and correct
Date,
Phone#: g D
Official use only. Do not write in this area, to he 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 S.Plumbing Inspector
6. Other
Contact Person: Phone#:
MAR/31/2011/THU 01 ; 43 PM FAX No, P. 002
OP ID:R
CERTIFICATE OF LIABILITY INSURANCE DP11E(rnM1°DmYY,
03/2411
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON-THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIPICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING )INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the oertlfl¢ate holder Is an ADDITIONAL INSURED, tho policy(les) must be endorsed. 9 SUBROGATION 13 WAIVED, subjeot to !
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this eertlfleate does not Confer rights to the
cortlFlcate holder in lieu of such end°reement e.
PRODCCER 781-914.1000OON
Thomas Gregory Associates Inc. 781-246.2B01 PHON!
601,Edgewater Drive 3235
W�+afield,MA 01990 -MDL
Mllam J.Surette PRODUCER
CRANNCO
INSURE 9 AFFORDING COVER G8 NAIC 9
INSURED Cranney Cornpanles,Inc. INSURFRA:Netherlands Insurance Co
j attn.Paul Cranney msuRrmB:Excelsior Insurance Company 11046
10 Rainbow Terrace iNsuggacAorth River Insurance Coinpany 21106
j Danvers,MA 01923 D
URERS:
IINSURER P,.
j COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS,
EXCLUS(ONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAYHAVE BEEN REDUCED BYPAID CLAIMS,
AIDDL SU SR TYPEOFINSURANCE POLICY EFF LIMITS
OENERALLIAb1LITY EACH OCCURRENCE 3 1,000,00
A X COMM ERCIALOENERALLIASILITY CBP 340 43 40 02129/11 03/26112 oc
EMISEB Eeaurrenoe E $00,00
CLAIM8-MADE Z OCCUR MEDEXP(Anyone person) a 16,00
PERSONAL 1&ADV INJURY s 11000,00
GE14ERAL AGGREGATE $ 2,000,00
OEN'LAGGPEGATELIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00
POLICY x PRO LCC $
AUTOMOISIL9 LIABILITY COMBINED SINGLE LIMIT
• (Eoaarldonq $ 1,000,00
B RNYAUTO BA 8400763 03126111 03/26112 BODILY INJURY(Perperaon) S
ALL OWNED AUT08
BODILY INJURY(Parsacddenq S
X 6011EDULEDAUTOB PROPERTY DAMAOE' $
X I•IIREDAUTOS (ForamldenO
X NON-OW14EDAUTOS $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE s 10,000,00
RXCESSUAB CLAIMS4AADE AGGREGATE $ 10,000,00
C 683-094116-2 03125/11 08/26/12
DEDUCTIBLE S
x IL. g
WORKERS COMPENSATION x. T TU-
AND EMPLOYERS'LIABILITY
B ANY PROPRIET DWARTNER/MCUTIVE Y f N WC 840 47 40 03/26111 03129112 E.L.EACH ACCIDENT $ 1,000,00
OFFICERIMEMBEREXCLUDED? L_J NIA
(MandAlory In NH) E.L.DISEASE•EA EMPLOYE a 1,000,00
If RIPWeUnder E.L.016 EASE•POLICY L s 1,000,00
0 Days Notice of CANCELLATION
appllesfor NON-PAYMENT OF PREMIUM
DE8 IPTIO F PE TIO SI LOCATIONSIVERCL28 AaeohACO D1 1 d l o f emerke3che I t el ra u d
xx;ktia�xvxp xxzxxxxxxxxxXXXX)MXXxxx�Cx>�x lC (xxXxxxtx3t�C��t3c�f x x c;axxxx
xxxxxxxxxXXXXXXxxxxxxxxxxxxxxaaxxxxxxxxXXXXXXXXXXXXXXXXXxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxXXXXXxxxxxxxxxxxXXXXXXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxXXXXXXXXXxxxxxxxxxxXXXXXXXXxXXxXXXxxxxxxxxxxxXXXXxxxxxx
CIERTIFIC&T&HOLDER CANCELLATION
EVIDENC
6FIOULO ANY OF THE ABOVE g23CRIBED POLICIES BE CANCELLED REVORE
THE EXPIRATION DATE THEREOF, NOTICI; WILL BE DELIV$RI:O IN
Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxXxxxl(70(xXxxxxxxxxxx(XXXXXX AUTHORIZED REPRESENTATIVE
)(](XXXXXXX)txXXXXXXXXXXXXXXXXXXX �
xxxxxxxxxxxxxxXxxxxxxx,XX xxxxxxxxxX
®1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD
COMMONWEALl"H OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS
LICENSEp AS A MASTER' pCUMBER '
N ..:CORP.:
. :. -E , STEREO AS A PLU .•B! •
ISSUES THE ABOVE LICENSE TO.," =
.:A40R,M;AM R ST HILAIRE,, .JR;..
_ ' ''. .'''ISSUES THE ABOVE UCENSE TO:•':'
:.NO.R.MAN R ST HILAIRE "'.'J:R
-' .:. . CR
18Q:•.NEWBURY ST ANNEY COMPANIES INC..
APT .61407 , . 160,.;NEWBURY ST
. . . .APT.' 6.407
DANVERS MA 019'.2.3r'52;5p: DA:NVEIt$ MA Q1923-53,.0:
9761 05/01/12 ' 78856 26
66 05/01/12 y8856
COMMONWEALTH OF MASSACHUSETTS �',".':;- :C,.OMMONWEALTH OF MASSACHUSETTS':'
L IF60 ED AS A MASYER GgSFI: ER',. -" ;�
ABOVELICENSET 1:"`;.-.,1ICENSED AS A {1
' JOURNEYM.
ISSUES THE Q: - :.-_..-.
�A9QV� SET!?:.;:-;. --
UES.7HE LICEN
, NORMAN R ST HILAIRE J'R - -
_ _
R:'191LN>f- ,R �ST HILAIRE' :f'#2 :.
1:80:. NEWBURY ST �: - _
APT... 6407 ;•':,... ';B =: B
• W RY '.S .;•.
DAN.VERS NA QI9.
2.3-5Z .0..
-
I_,,' A�1 ,ERS
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B877 05/01/12 ::7g85i I,.^;,.,�:;,::::,:_.:.-:;::':'. . _ _ 2:3:::: 3`,
2 p -
�4
a �I J / Date................................../
NORTF�
0��,�to a•,�
3r ,• ;•°oma TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�,Ss lCHUSE�
This certifies that
................................................................. .........................
has permission to perform
. ......... .............................................................
wiring in the building of.......... �.E U !z?. 4. `..............................
at..................... ........ '..... D Q .........................., rt Andovei,ass.
aoo�Z
ti Fee..:fit ga..... Lic.No.............. ..Z'...............
l ELECICAL INSPECTOR'
Check # ! ��� TR
i M�a
lfommonwealtk o f/�/amacku,6ette Official UseOnly
2cc�� cc77 Permit No.
epartment of ire Service9
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(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYP ALLFORW TIQN) Date: �- 1� - `I
City or Town of: n( ��J l}e-r 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) S�� S -) S-�(;ee V
Owner or Tenant 'j�-Cw perlp,,-V Telephone No. 52)-q`�
Owner's Address 5 `1_S Se
Is this permit in conjunction with a building permit? Yes 2, No ❑ (Check Appropriate Box)
Purpose of Building Utili Authorization No.
Existing Service Amps \;LZ) /c-iZ� 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:
3
Completion of the following table may be waived by the Inspector of Wires.
1No.of
No.of Recessed Luminaires No.of Ceil.-Susp (Paddle)Fans Trans
Total Trsformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
of
No.of Switches 3 No.of Gas Burners No. InDetection and
Initiatin Devices
Ranges No.of Air Cond. Total No.of Alerting Devices
No.of Ran
g Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals:I I I Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KWLocal❑ Municipal [I Other
1•�7 Connection
No.of D Heating Appliances KW Security Systems:*
Dryers No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts I No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications
No.of Devices or Equivalent
OTHER:
00 Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: ����. (When required by municipal policy.)
Work to Start: `1 0 Inspections to be requested in accordance with NEC 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 Z BOND ❑ OTHER ❑ (Specify:)
I certify,under th�Eains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: ts 4-1t 1 Q.C. ,i (J , Cs`S LIC.NO.: DnO
Licensee: ���,v,r i s Colo Signature LIC.NO.:E 0 t Z
(Ifapplicable,enter "g�em11��t', - the cense number line.) \ Bus.Tel.No.: �1�� X1-1 3
Address: lD l,00l� o,t ��+\gSbt�G 0 VNA ����� Alt.Tel.No.: °I'1g (,uct'3`1�3
*Per M.G.L.c. 147,s.57-61, ecurity work requfresbepartnidnt 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 aent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
e
3
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r
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•
1
The eonitnonwealtlijofMsacl:usetts
�epar6neizt'd fIiidusirinl,Qccidents
Office of-Investigations
600 Washington Street
Boston AL4 02III
`mm mass gov/dia
In
Workers' Compensation Insurance Affidavit:Builders/Contractors/El lecfricians/Plumbers
A Pli Information
Please Print Legibly
Name(Business/Organizatioh/lndividvat): S C kCj SA I
Address: `b -zv,&_
City/Stat e/ZiP 5 b vro 1'�At\_ Phone."
- of -
Lre
an employer? Ch ck e appropriate box: # 3
a employer with 4. 1 am a general contractor and I Typeofprojeet.(required):loyees(fall and/orpart-bine),* have hired the sub-contractors 6: ❑Ne construction
a sole proprietor orpartner- listed on the attached sheet 7. [ t5N'con trand have no employees These sub-contractors haveing for me int any capacity. employees and have workers' 8' ❑Demolition
workers'comp,insurance comp.insurance t g- ❑Buiilding addition
red.] 5. We are acorporation and its 10.❑Electrical repairs.or additions
a homeowner doing all work. offcets have exercised their1I.�Plumbing rlf. [No workers'comp, right of exemption per MGLeP or additions
ance required-1 t c. 152, §1(4),and we have no 12.0 Roof repairs
employees.[No worIcers' 13.[]Other
comp.insurance required,]
;Any applicant that checks box#]must also fill out the section below showing their workers,co
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside co tractors Policy submittaaa new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. Irthe.sub-contractors have employees,they must provide their work
ers•comp.policy number.
I am an employer that is providing workers'compensation fnsurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: IrAn , 0
Expiration Date:_
Job Site Address:__ SS Q1X "i�-. R
City/state/Zip.-_—A) , �4,0�. 1C\
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 ofMGL 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 under thepains and penalties ofpedrery that the information provided above is true and correct.
Signa ure- �L- �
Date:
Phone#:
FrI19SUingAiuithority
only. Do not write in this area,to be completed by city or town official
n: PermidUcense#
hority(circle one):Hen" 2.BuildingDepartment 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
rson:
Dh.,....40.
RTH
Town o.JLL Andover .
OVO
q.nMv,.b 'L •I',
No. 310
A K O dover, Mass.,
GOC HICHEWICK ��
ADRATED P'Posl �
`s U BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT..... ............ ............ .:f........I........... ..................................................... Foundation
has permission to erect........................................ buildings on .....��..Z......... ....... ........... ......................... Rough
ICS
.(. ..a. ........................................................................ Chimney
to be occupied as..................` . h
provided that the person acc ting this permit shall n very respect conform 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
PERMIT EXPIRES IN 6.MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUVL
TS 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.