HomeMy WebLinkAboutMiscellaneous - 550 TURNPIKE STREET 4/30/2018 (13)Lr
Location ��l�E��/
Date
e ' TOWN OF NORTH ANDOVER
e
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee /6rw $
TOTAL $-
C h e c k
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25082 Building Inspector
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NORTH ANDOVER CROSSROADS LEWTED PARTNERSHIP
820A Turnpike Street, North Andover, Massachusetts 01845
(978) 689-0800 FAX (978) 794-0890.
Business Office:
861 Turnpike Street
North Andover, MA 01845
(978) 686-7200
(978) 686-4314 (Fax)
March 8, 2012
Attn: North Andover Building Dept:
Please be advised that iMobile, LLC has our permission to install a sign at our North Andover
Crossroads location.
Should you have any questions please call me 978-686-7200.
Regards,
Trisha HH
Office Manager
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Datel—W -/ .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... S -.P . ...... .............................................
has permission to perform ....
wiring in the building of ............................
at................... North Andover, ass.
Fee..q:c * 91
..... Lic. No...15� ......
ltl�p E",e C�L
Check # l
060A
Q
y (fmmonweaGth of kamsaclwelb. Official Use Only
2epaniment o f —7h. Servim Permit No. l�
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), 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPEAL INFORMATION) Date: -
City or Town of.0IJ- 14A40v4pZ 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) <S0 Tc/riy o/1C- QST
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes D<r No ❑ . (Check Appropriate Box)
Purpose of Building 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:re Al, (J(f',"
Completion of the followine table may be waived by the Inspector of 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- ❑
rnd. nd.
o. o Emergency ig ng
Balm Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of De echon and
Initiating Devices
No. of Ranges
No_ of Air Cond. Total
Tons
No: of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
I Tons
KW
-�"
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No..of Devices or Equivalent
No. of Water K`,4,
Heaters
No. of No. of
Signs Ballasts
Data Wiring: /
No. of Devices or Equivalent h
No. Hydromassage Bathtubs
No. of Motors Total HP
Te ecommunicationsWiring:
No. of Devices or Equivalent
OTHER:
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: immediate1inspections 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 pains and penalties of perjury, .that the information on this application is true and complete.
FIRM NAME: S R Dodge, Inc. LIC. NO.: 15 . 064A
Licensee: Richard H. Dodge Signature LIC—NO.: 15064A
(If applicable, enter "exempt " in the license number line.) Bus. Tel. No. 781-279 —1300
Address: 12 Spr-ncrPr St-rc-_c-t-{ . Stnneham{ MA 02180 Alt. Tel. No.: Game
*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
Signature Telephone No. PERMIT FEE: $ o%r—
L"
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractoxs/JEiectricians/PIumbers
Applicant Information �/� Please Print LeZibl
NaMe (Business/Organization/Individual): � F ,QAe-
Address:
City/State/Zip: S ,1��Phone #: 761-,921-1306.
Are you an employer? Check the appropriate box:
1. �" f am a employer with /d
4• F1I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. FIN e onsiruction
7. emodeling .
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roofrepairs
13.❑ Other
*Any applicant that checks box R must also Ul 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Policy # or SeIf-ins. Lie. #: �� S"f)i��/l%c� ��1 ✓✓�✓�� Expiration Date: % .Z
Job Site Address:, s %hU►'Z�N(C' Cf i City/State/Zip: ) Axe, -
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.
Ido hereby1t4erti}Ly under thq4lrajn�andpenaldesof,
that the information provided above e and correct.
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. EIectrical Inspector 5. Plumbing Inspector
6. Other
C ontactPerson:
Phone
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