HomeMy WebLinkAboutMiscellaneous - 575 TURNPIKE STREET 4/30/2018Date ....Y -IL. —0............3
......
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
Thiscertifies that ...... .................................................. .�...............................
` �fCt�i S S
has pc�fmission to perform .......... ............................... . ..........................
wiring in the building of... f3 A K'
................................................................
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.�.6��• ,orthlAndover, Mass.at ....L... . .... ....!.....:........................
D --Cb a1....
Fee..... Lic. No. ........................ .................
ELECTRICAL INSPECTOR
Check # rj `) D
446:
THE C0MM0IVWF•AL7H0FMASS4CHUSE77S
DEPAR7NW0FPUBIlCS4MY Permit No.
BOARDOFFMPREVEMONREGUTAH ONS527CAM12.W
Occupancy & Fees Checked
tPLICATIONFORPERAIHTTOPERFORMELECMCALWIORJ�
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 f
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date / L d
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street &Number) 75— %(/��,J/k C ' S -r
Owner or Tenant rrT -h m,p
Owner's Address /nG -f L a 1 nsc�
Is this permit in conjunction with a building permit: Yes ED No ® (Check Appropriate Box)
Purpose of Building RK &Y 72�- /ate Utility Authorization No.
Existing Service Amps�Volts Overhead M Underground No. of Meters
New Service Amps / Volts Overhead 1=1 Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work %/t/'�T�f/ Chu/�'.c�i✓� J ys�,
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVAKVA
No. of Lighting Fixtures
Swimming Pool
Above
Below
Generators
ground E3
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pum s
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local� Municipal
Other
No. of Dryers
rY
Heating Devices KW
Connections
ED
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER-
ItS111anoeCovezage. Rmanttoth-,wqimanallsofMassmhusettsGalaalLaws
IbawaamertLmblh'tyhlsa m=Pbbcyurkxbr gGm
IhavesubmiWdvalidpcdcfsarnetotheOfliae. YES
checkingfM box �� L
INSURANCE BOND OIFER
WodctoStatt � kgXrfimDalcRequested
SignedunderTr ofpeju1..
FIRMNAN E/, a� �� c.��17Z /.y6-
Iicatsee \)a, . 111a'aK/s sigum
OWNER'S INS UR ANCE WA N I R : I am aw.
and thatmysignahueonthispemritapphca6mwaivesthistegtmentt.
(Please check one) Owner Agent F1
Signature of Uwner or Agent
aala>t YES LZJ NO LJ
Fyouhavecf mkodYES,pbmirdiratethetypeofcoverageby
may)
Exp6timDaIe
EsmrtatedVahteofl bcfiiralWotk$
Lio wNo. / 3 -7�-6-
Li mNo
BuskmTel.No. a n 9
A1tTUNo.
ted byMassadIumGenedLam
Telephone No. PERMIT FEE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02919
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City Phone #:
Insurance. Co. Policv #
Company name:
Address
City: Phone #
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1.500.00
and/or one years' irrprisonmentas_re!]Las_civil.penaltiesinsbeinun_fa_S?QP WORK ORDERand afire_cf_(,$11a0,0D),atlay,againstme, I
understand that a copy of this statement may. be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under Me pains and penalties of perfury that the infarmation provided above is true and correct
Signature Date
Print name P one.#
Official use only do not write in this area to be completed by city or town official'
City or Town PermitA icensing
Building Dept
C]Check if immediate response is required [j Licensing Board
p Selectman's Ohice
Contact person: Phone #: E] Health Departigbnt
Ei Other
Location
No. 0 3 4 Date
TOWN OF NORTH ANDOVER
F n Certificate of Occupancy $
+ ; ; Building/Frame Permit Fee $
�ss�cHuSE� Foundation Permit Fee $
OJpther Permit $
P�rIr on Fee $
,EEr
} Water CoTgVion Fee $
TOTAL $
I+ol, Andover
Building Inspector
Div. Public Works
Location
No. Date
NORTp TOWN OF NORTH ANDOVER
O? •.� 1 ' —1h a p�
°p Certificate of Occupancy $
°sipsats Building/Frame Permit Fee $
�'+b"'•°''��' Foundation Permit Fee $
Ss�CHust
bb t
Other Permit Fee $
e� FSer P., p�, I c MjPee $
Water Connection Fee $
TOTAL $
Mo. Andover Cellecto
Building Inspector
Div. Public Works
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