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HomeMy WebLinkAboutMiscellaneous - 60 COURT STREET 4/30/2018 60 COURT STREET � (O -- - 210/095 00000. r 1 r '1 Datc� "•��T:��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS US This certifies that has permission to perform plumbing in the buildings of 0 f ivJz�O.'. . . . . . . . . . . . . . . . . . . . . /aa at. ✓.2'']""``,�... . . . . . . . . . . . . ort d v Mass.r �fG!. . Fehr„ d . ..Lic. No.. . '''. . � . . . PLUMBING IN ECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA. DATE IPERMIT# Of 9TELJOBSITE ADDRESS ( - OWNER'S NAME P OWNER ADDRESS: V, FAX:�..� TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: . PLANS SUBMITTED: YES❑ NO FIXUTRES Z FLOORS Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR/AREA DRAIN ' INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL =RVICE/MOP SINK r01LET URINAL CWASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑■ NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE 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 [I AGENT ElSIGNATURE 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 all plumbing work and installations performed under the permit issued for this applicati�will be in compliance 'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME:I MICHAEL HOUSE LICENSE# 7173 SIGN TU RE` ?MPANY NAME: MERRIMACK VALLEY CORPORATION ADDRESS:Ll5 AEGEAN DRIVE,UNIT 3 CITY: METHUEN STATE: MA ZIP: L01M4._.. _ FAX: 1 978-689-2206 EL: 978-689-0224 —1 CELL: 978-884-3427 I EMAIL: LLITTLE@MVALLEYCORP.COM MASTER M JOURNEYMAN❑Q CORPORATION❑■ # PARTNERSHIP 0# LLC❑# y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): Address: .,� City/State/Zip: 7,/t)z.J �i / Phone#: �`�� -C7501. Are you an employer?Check the appropriate appropriate box: Type of project(required): 1.� ' employer y 1 am a em er with � 4. F-1I am a general contractor and I i employees(full and/or part-time).* have hired the sub-contractors 6. E]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. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9. E]Building addition required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.DPlumbing 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 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /r/,6 _�AA6e%1107 1eA1W1 A&; z^ L'o V Policy#or Self-ins.Lic.#: Expiration Date: t1l, /3 Job Site Address: i2Y` `�i��LGCity/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 ce Vuade the pains d enalties of perjury that the infor tion provided/�boZ,4_9k__3 true and correct Si nature: � /� r19pC�(� �' Date: 7-7 Phone#• 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#: 1, Location (moo No. Date � � NORTH TOWN OF NORTH ANDOVER F p 4K Certificate of Occupancy $ cMustt� Building/Frame Permit Fee $ �--�- Id Foundation Permit Fee $ Other Permit Fee $ TOTAL $ d• sJ+ Check # Awl- 2' 8 7 wl287 aBuilding Inspector TOWN OF NORTH ANDOVER A�Dere 1�3P�� �vcr BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RKNOVAZ OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: deA DATE ISSUED. SIGNATURE: Building Cotllmissioner/I r of B Wings Date SECTION 1-SITE INFORMATION Ir� 1.1 Property Address. 1.2 Asseuors Map and Parcel Number: �0 C6tJ 2T S r►- Map Number Parcel Number 1.3 Zoning Information: Y 1.4 Property Dineasiona: RtsuLT (IKS(�'� LIV, Zoining District Proposed Use Lot Area Fronts 8 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Wats Supply M IL.CAa.1 54) I.S. Flood Zoae lube nation: 1.2 SewaW Disposal Syateas: Public ❑ Private ❑ Zoua OubWe Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNER-SF"/AUTHORIZED AGENT NO r 2.1 Owner of Recoor►d.. S ccaCC.I ! Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si tura Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor C License Number .� q St r} LA I � 7 Expiration Date a� Signature Telephone r 4� -0 3.2 Registered Home Improvement Ctrraa for Not Applicable ❑ Company Name o rf G� � � l 1 t �� i �M1 ,,,�1 `a_` Registration Number r t n ) 1 ` �L 1 ,�`'�" Address OWN Expiration Date 2 Signature Telephone Y, t f SECTION 4-WORKERS COMPENSATION(M.G.L C 152 f 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 buildins permit. signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description oiProposed Work theekat bb New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) Addition ❑ n.. Accessory Bldg. bemo ition ❑ Other ❑ Specify a, "E Brief Description of Proposed Work: bu, d w A 6I 0tpa 4e /9 n6 13 patio,o . Lle SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant. I. Building �}} (a) Building Permit Fee QV r UV Multi lien 2 Electrical (b) Estimated Total Cost of 00 C/ Construction 3 Plwnbing Building Permit fee(a)x(b) 4 Mechanical HVAC 5 Fire Protection P9 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Zd L/ C U C/ as Owner/Authorized Agent of subject property t Hereby authorize o act on { My ,in all" relatitow uthoriz by this b Iding it application. r Si t er Date SECTION 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 4 Si ture of Owner/Agent Date N NO.OF STORIES a2 SIZE o?O(� S c BASEMENT OR SLAB SIZE OF FLOOR TIIviBF.RS K 1 cZ3�/ 2' 3Ku SPAN Q DMIENSIONS OF SILLS DD ENSIONS OF POSTS e—eq G( DU ENSIONS OF GIRDERS fZ /O HEIGHT OF FOUNDATION _ THICKNESS SIZE OF FOOTING ry X MATERIAL OF CH54NEY 1S BUILDING ON SOLID OR FILLED LAND 0 LI IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility)-) Sig atu a of Permi Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i 'g ✓ Z00��7/7TW�I8Ll GfN•' fY BOARD OF WLDi C-REGULATIONS ; ° - License: CONSTRUCTION SUPEHVtSOF ; f K Number-"GS 088997.' Birthdate 6410-9/1969 r Expires:,0910912007 Tr.no: 8899711 Regtricte{c� MIC6AEL V MANNtI! 7 SENECA ST ' F� METHUEN, MA 01844:; Commissioner a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston,MA 02111 �•�� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information / Please Print Legibly VIA Mo(Business/organization/Individual): �i�AZ, M o Il A Oe�P_c-IT/ C� Address: City/State/Zip: �'`e_kk,0_es Phone#: ct`7 q2 3 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 6. El New construction employee's (full and/or part-time).* have hired the sub-contractors $ 7. Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their I OXWectrical repairs or additions 3.❑ 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 12.0 Roof repairs insurance required.] t 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 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracton 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: AZA1 l4ttrud/ Policy#or Self-ins.Lie. #: V ui c- ('0049A Doi -),004 Expiration Date: l Dk'/ a✓ Job Site Address: CI6 =C�y�i'� S4--) City/State/Zip: fes, O W(? (S I 0 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-yearmprisonment, 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 MxdK tip pains a d penalties of perjury that the information provided abov is rue and correct: Signature: J QQ Date: Phone#: ��� 1 ��� /6 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#: 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 enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee 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 occupant 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 be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing 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-contractor(s)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 affidavit may 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 Industrial Accidents. 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 that 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts ` Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia NORTH Town of 4Andover h L A E o dover, Mass., w/%-,-wps, �� • COCMICMEWICK 7�S RATED PP�,��� • BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System ' • BUILDING INSPECTOR THISCERTIFIES THAT .,.............................................................................. ..................................................... Foundation has permission to erect........................................ buildings on A0....... ...... ... .... .......,, ..................... trough t0 be Occupied 8S . ...................................................................... Chimney .. . . . . . . . .. .. 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 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. trough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR ....... JY` Rough . ervice BUILD G 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. Location No. Date �aRTM TOWN OF NORTH ANDOVER F? • • L9 Certificate of Occupancy $ ' Building/Frame Permit Fee $ �'�s'•°•'�cn Foundation Permit Fee $ s�CHU Other Permit Feed $ � Sewer Connection Fee $ `o- Water Connection Fee $ TOTAL $ �Builcling Inspect r08/06/96 10:12 45.00 7 6 Div. Public Works kation r ` r No. Date J y MORTM TOWN OF NORTH ANDOVER O? • ` O R p Certificate of Occupancy $ s i # Building/Frame Permit Fee $ �7b'••"''t� Foundation Permit Fee $ s1ACHUSE I Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ / TOTAL $ e Building Inspector 08/06/98 10:12 45.00 PAID J Div. Public Works PERMIT-NO- APPLICATION FOR PERMIT TO BUILD********N RTH ANDOVER, MA AIAP NO. LOT.NO. ©/ ?Z\ 2. RECORD OF OWNERSHIP DATE BOOK PAGE ZONE SUB DIV. LOT NO. �P LOCATION PURPOSE OF BUILDING OWNER'S NAMEC +�`\ NO.OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCI it"TECI'S NAME SIZE OF FLOOR TIMBERS I ST 2ND 3 D BUILDER'S NAME ; e SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS Of POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT CIF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CIIIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL.BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTUCTIONS 3. PROPERTY INFORMATION LAND COST ti EST.BLDG.COST OQ PACk I FILL OUT SECTIONS 1-3 EST.BLDG.COST PER SQ.FT. EST. BLDG.COST PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING. 'TOR DATE FILED �j OWNERS TEL# CONTR.TEL# C CONTR.LIC# ?SIGNATU E OF OWNER OR PL'IORIZED AGENT FEE $ 4fef PERMIT GRANTED 19 � N�Hr Town of _ :_ Andover No. 30;-9 dover, Mass. 19PF Q LANE CO CHIC HE WICK r nP�� - '9 �9gTED PP �J SS' BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT.......................... . . ... ... ............... Foundation has permission to ere .. . ....... �............. buildings on .... .Q....... ..................................... Rough to be occupied a .. .. .. .� . Chimney provided that the person acceptin is permit shall in every re:.2. 11 c8nform to the terms of the application on file in Final this office, and to the provisions the Codes and By-Laws relating to the Ins_pection, 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 UNLESS CONSTRUCTION STAR 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 RoughFinal No Lathing or Dry Wall To Be Done .Y Until Inspected and Approved by the Building Inspector., FIRE DEPARTMENT tBurner Street No. Smoke Det. ` n i Date.... .... . .. '..... . .... 's f AORTO,, 3r0.�;� .:°•,M��c TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS� . This certifies thaf'_'"`.,''`-'.-,-�^--+•"$.....c.............................................. has permission to perform-,----4,�� f�....� ��* :1................... wiring in the building ...................................... ......C— ............................... .North Andover,Mass. Fee. ? ................ Lsc.No. A/ ..... .......................'. .................... ELECTRIF AL INSAE�'oR Check r--4-96 9 56, 35 1170 t.UiMVIU[Y"r.HL.!n Ur XAtUM at1nv.wA 1 u �•••-�--- ••, DE@!li<nMEN 'OFPUBW AMY Permit No. BOARDOFFMPREVEMONR7below. M70MIZ- D — -� - / Occupancy&Fees Checked APPLICA77ON FOR PERMIT TO PELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSTRICAL CODE,527 CMR 12:00 / �- PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat 6 9&; S Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wo descLocation(Street&Number) Owner or Tenant LOLJt S tA" N Uczr 5V2_ Owner's Address X31 N- ��V o2 Is thisP ermit in conjunction with a building pennit: Yes® (Check Appropriate Box) Purpose of Building �1Jo 0 7ANLZ�> Utility Authorization No. Existing Service -00 Amps 416 Volts 6verhead rM Underground No.of Meters New Service Amps. Volts Overhead Q UndergroundNo.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work S v`tQ L) M rC S P U (22� No.of Lighting Outlets No.of Hot Tubs No.of Transformers Tota! KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground 173 No.of Receptacle Outlets No.of Oil Burner No.of Emergency Lighting Battery Units No.of Switch Outlets . No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons �+ No.of Disposals No.of Heat Total Total No.of Detection and Puma . Tons KW Initiating Devices No.of Dishwasher Space Area Heating KW No.of Sounding Devices No.of Self Contained r Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other ConnectionsNo.of Water Heater KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motor Total HP OTHER It>a==CUWrW PuM=1DdrwWnwlsofNbmKh=ftC=ed1m i a Ihawaa=tLWA1ybWZ=F0LYi�Ldr�gtds oslAarialagtivala�t YES NO Itxmsubnimdvddp Ycf=retoQieOffm YM M ff}whmdrd®dYfs'S,pleawaQt 11Ar0faov=Wby BOND OHM E] ftw** /0 Estin*dVatiedE1s cEdWadc$ WodcbStat h>spact mD*Re rAW Ra>gtr C– Fred of, FIRMNAME 7A�Y1 . LiwwNa I D 1 BtLsk=TbLNa ALTdNa OWICSRMRANCEWAMN41ammmedildieLwwdDmmthen ftkm nceaom*critsabt3rialtxltavalmiasmgimdbyMa CO,WLam and that my sigr>atine on thisPlum app6ca6rn waives alis tegiaarlait (Please check one) Owner Agent Telephone No. PERS FEES"` f signaturew ""' JIM l IMVIUIY"rdU.LL1 Ur o DEPARTM©VKI'OFPUB ESAMY Permit No. Da4M0FF=PRLVBV1WREGUlAT9027QM12-W Occupancy&Fees Checked APPLICA77ONFOR PERAffTO PERFORM ELECTRICAL WORK CALLWORKTO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 SE PRINT IN INK OR TYPE ALL INFORMATION) Dat 6 Jq c s 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) Owner or Tenant C,DU l S wt N 2c LJCZ "T' TO Owner's Address �3 l S�,�"� N- A�-' ►r LJ is this permit in conjunction with a building permit: Yes® [:] (Check Appropriate Box) Purpose of Building l rJ� d Utility Authorization No. Existing Servicec�—)40� Amps la.U-olts 6verhead rM Underground No.of Meters New Service Amps olts Overhead Underground Q No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work St`n6VxG'(()e 5 cz,P 77 U F 7 77(1� No.of Lighting Outlets No.of Hot Tub No.of Transformers Told KVA No.of Lighting Fixtures Swimming Pool AboveBelow Oeneratas KVA nd anti No.of Receptacle Outlets No.of OU Burnes No.of Emergency Lighting Battery Units No.of Switch Outlets No.of On Burner No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No. f No.of Disposals No.of Had Total Total No.of Detection and �J Pumps . Tons KW Initiating Devices No.of Dishwasher Space Area Heating KW No.of Sounding Devices No.of Self Contained DetectiordSoundieg Devices No.of Dryer Heating Devices KW Loci Municipal Other Connections No.of water Heaters KW No.of No.of sign Bailasis No.Hydro Massage Tab No.of Motors Total HP OTHER• huz=CovaW Arm niDdzw imimft fNlmFdhmftCknsdIAws Iha�eaatta3tLieht6iyhvataePta6ryircldr>gUor►lp� —n orilsstkdxMa4jvdst . YBS NO It>tt�suhrrriodvaidpodafsemeafe011kz YPS lf)whnedrd1adYfMpk,=ildraledr t,%Wcfo wvVby DZUIANM b� BCND OMM r ,o/as- FsWn*dVaireafEhmcdWadc$ Workioswt f 3>Spac�otrI)MIR 1sw Rotor �' Atld Sgoad ,v ,= /-�n�Mc�LA rl-5?���-rr A S'UC, I; Na77 A l 46) S�pm Iioe =No Budn=TdNa AXTdNa COWi�R'sIlVStJRAN(EWANFR;Iamawa�thetdieLioaned�rotltmedeirmtanoeao�al�oritsslb�rrialagiivalaltaslac}riedbyHles�d><�sGe�rali�vt+g i std drt my s�latae rn tills -k- Icmon wai�ex tills Iegilier,att (Please check one) Owner 1:3 Agent 0 a v Telephone No. PERMIT FEES 1 Signature