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HomeMy WebLinkAboutMiscellaneous - 66 HAY MEADOW ROAD 4/30/2018 (2) 66 HAY MEADOW ROAD 210/104.8-0103 0000.0 ................ 0,.140 TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU This certifies that has permission to perform ... ...................................................................................... ........... wiring in the building of........�-.kxx..�kXA............................................................ mat ............ ........... A- . l............. . I No h Andover,Mass. Fee Lic.NoA-361... ............. .......... ............ ...................... ECTRICAL �giL i INSPECTOR Check* :3(Apo 11566 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (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 TYPE ALL INFORMATION) Date: M (a City or Town of: NORTH ANDOVER 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) K6 14AY e A4; Owner or Tenant S"l eve. /Z ,R I c i L- Telephone No. Owner's Address AMeAdg,LJ Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of BuildingINs3 Jrj n. Utility Authorization No. & f r/ - Existing Service Amps / Volts I Overhead ❑ Undgrd❑ No.of Meters I New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: PIA lC '-Le-0 !' P I21 P O-R SaCk l Completion of the following 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 ❑ In- ❑ o,oUits Emergency Lig ting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switclies No.of Gas Burners No.of Detection and Initiating Devices 1 No. of Ranges No.of Air Cond. Total g Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: Detection/AlertingDevices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW SecN.of Systems:* or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: .. No.of Devices or E uivalent OTHER: Adach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: so GL (When required by municipal policy.) Work to Start: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury,that the information on this application is true and complete. �! FIRM NAME: . C k1.L1n A., I C1N C LIC.NO.: v -t Licensee: Na cc U netq,,,r/-/ Signature c LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: Address: Alt.Tel.No.: *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 PERMIT FEE:$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions 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 1 on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an { electrical permit shall be 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 may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work 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 promote job 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 qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INS ECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: - 4 J' cLj�.r Inspectors Signature: G Date: PARTIAL ROUGH INSPEC N: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial 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 Leizibly Name(Business/Organizationgndividual): Pl1 Q 1 �� Address: 1-?2idiC 2d Ci /State/Zip:. o.i I Pn 1 d Phone#: 7 F -3 7 5 Are y 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Buil ' addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10. lectrical repairs or additions required.] officers have exercised their 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.E].Roof repairs insurance required.] 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. I Homeowners who submit this affidavit indicating they&ie 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 isproviding workers'coin enaion insurancefor my employees. Below is thepolicy andJob site information. � Insurance Company Name: (R,,L,,Ve l (-n S �/�'S!'n p�l>✓ Policy#or Self-ins.Lie.#: G T1 3 1 Expiration Date: Job Site Address: 1 f A d b City/State/Zip: ti��`-t�6l��r� /-VIA Attach a copy of the workers'corfipensation 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 cert under the ains and penalti of perjury that the information provided above is true and correct. Simature: ) Date: 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#: r 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 r 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 oflndustrial,Accidents Office of Investigations 604 Washington Street Boston,MA.02111 Tel,#617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 www.mass.gov/ilia �.M Date. ........-.Q .......... NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACNUSE� i This certifies that ....... ...................................... has permission to perform,1,..x-'�-'r. .. (�.. wiring in the building of...... ,,.�...� ............................. at ..... ! :........ ,North Andover,,Mass. Fee ............... Lic.NoA5 / i./f ELECTRTCAt INSPECTOR Check # 5511 TBE COA MOArRF.ALTHOFA MSSAMUSETTS Office Use only DEPAITA1EVT0FPUX1CSAFL7Y Permit No. RD BOAOFF=PREVEMONREGULAHONS527CMRI2:Gn Occupancy&Fees Checked / APPLICATTONFOR PERMFT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (� Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wokdescribed below. Location(Street&Number) to� )4,4 IWA, io-uj Owner or Tenant Owner's Address Is this permit in conjunction with a buildi g permit: Yes No (Check Appropriate Box) Purpose of Building J Utility Authorization No. Existing Service Amps / Volts Overhead Underground No.of Meters New Service Amps Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work YL owcjv(f No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round round No.of Receptacle Outlets No.of Oil Burners 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 Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW NQ,:of Sounding Devices No',JofiSelf Contained Detection/Sounding Devices No.of Dryers Heating Devices KW LocalMunicipal Other _ Fi Connections L No.of lWater Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP THER �. UanceCovaage.Rua=tothetequheriaIisofMaMchusem Laws avea(amentLiabilityh>suracico 1 yinchxbgComple� CovetageoritsatsmntWequvalatt YFS NO avEsut�tnut�dvalidproofof totheOffx�YES ycubaw YES,pleasenxlcalethetypeo co by Ig;leff Q,vcEBoren OT R � (rim S"*) � , 7� d EstimatedValueofF lWbik$, xktoSW IrLmectionDateRe Rough Fugal �c/ ned Palattiesofpetjuty.MNAME JAAUC � It(C 11see � LicffwNo BusirmTel No. Ah Tel No. NT,'S INSURANCE WAIVER;I am awaile&tl>v Lice does riothave d-& coverage or its atgantial apNalent as w9med byMassachuscils Ce�Laws that my sig maeonthispeurntappficadonwaivesthismgmernent. ;ase check one) Owner ® Agent ® c� Telephone No. PERIMIT FEE$ lgna ure oT Owner orgen Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston; Mass. 02111 Wormers'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,afine up to$1,500.00 and/or one years'imprisonment-as vice➢_as_civil..penaltiesjn.tbefnrmof-a_STOP WORKORDER.and_a.fine_of.(.$1110..00.)_ajday-against.me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required p Licensing Board ❑ Selectman's Office Contact person: Phone#: Health Department Other Date . . . . . . . . . .... . .. . Of.NORTH 1 ' 02 °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .•`th �9SSAr.uSEt This certifies that . . . . . . . . . . . . . . . . ... . . . . . . . . . . has permission forgas installation . . . . . . . . . . . . N in the buildings of . . .�. � c -'. . . . . . . . . . . . . . . . . . . let at . . . . Gc ?u''. . . . . ., North Andover, Mass. Fee , . . . . . Lic. No.. r��. . �/._ . . . r� . . . . . . . . . /�i4S'INSPEGTVO Check# 4761 MASSACHUSETTS UNIFORM APPLICATION.FOR PERMIT TO DO GASFITTING (Print or Type) North Andover i //7(a c r' Mass. Date1 6r OU Permit Building Location-6F, Hatrmooa.,, Owner'sName Steve Kurkul h y Map: Lot: Zone: Type of occupancy__ 7'P1l d Pjltl al New Renovation '_1 Replacement P :1 Plans Submitted: Yes❑ No Fee: N N Y ¢ cc • rzn e g ozn as 1' ne $20.00 cn cn N W ¢ tn .. W N ¢ Z r- ¢ z J W o x _ t o o e t ,r ¢ < } m z ¢ Q O W < ¢ ¢ z O O ~ w ¢ m Cn W W O o OUj Z Z ¢ > Q WWWM _U U W W W < ¢ Q W Q r Z _ Q x ¢ ¢ 0 ¢ W W H 2 Z C W Q S 1- F W O LL F- U J N ¢ Q W > ¢ W M Z Q } N m Z O Z W O U) W ¢ x 0 ¢ x a x 3 ¢ < a o o w ¢ o W F- D C7 J U ¢ > a F O SUB-BSr,AT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR ,K 7TH FLOOR STH FLOOR Installing Company Name Q 4TER TTL rRQ-:; lT� & OTT INC. Check one: Certificate Address 131 WATER ST DANVERS M,�. 01923 Estimate Value of Work: +� Corporation � Business Telephone ,Q,t�;�_z�C ��7;:1 Partnership Name of Licensed Plumber or Gas Fitter = Firm/Co. t Talbot FINSURANCE COVERAGE: current liability insurance policy or its substantial equivalent which meets the requirements of MGYes`f No � L Ch 142. ve checked es, please indicate the type coverage by checking the appropriate box. A liability insurance policy;( Other type of indemnity ] Bond El OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my Signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued all pertinent provisions of the.Massachusetts State Gas Code and Chapter 1,42 of the eral application will be in compliance with By Type of License: Ttle plumber ign ture of Licensed Plumber or Gas Ftter Gasfitter City/-own Masser License Number1 (APPROVED I RJourneyman r�iCc USE -NLYI N2 2447 Date...... 4,, TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS US This certifies that ......... ........ . .............!n!.. .................... has permission to perform ..........ello�l......L�..(��..... miring in the building of...... ...................................................... at.......(2.k......... ........... .North Andover.Mass. Fee....f ... Lic.No.. ........... . %l !!. ..................... ;7Jl 'All-K.., / �RICAL iNSPECrOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Office Use Only - The Commonwealth of Massachusetts Permit No. 44 Occupancy& Fee Checked ' Department of Public Safety 3/90 (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 RULE 8 Effective 1/1/78 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORT All work to be performed in accordance with the Massachusetts Electrical Code,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date `123I$-©882 Yl C City or Town of AM 1L0 /? o 1/L,,, To the Inspector of Wires: The undersigned applies fora permit to erfor the electrical work desc ' d P P below. Location(Street& Number)__ J �lila A�y � I Owner or Tenant AfLVcJ�2 Owner's Address `n���/ e'q- o Z. Is this permit in conjurkcyon wit a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building GUtility 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 f No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above In- nera Getors rnd. ❑ md. ❑ KVA No.of Receptacle OutletsNo.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 No.of Detection and tons Initiating Devices No.of Disposals Total Total P No.of Heat Pumps Tons KW No.of Sounding Devices No.of Dishwashers Space/Area Heating KW No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local ❑ Municipal ❑ Other r Connection ( No.of Water Heaters KW No.of No.of Low Voltage Signs Ballasts Wiring 16 No. Hydro Massage Tubs No.of Motors Total HP Other: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts Generaws I have a current Liability Insuran Policy including Completed perations Coverage or its substantial equivalent. YES NO ❑ I have submitted valid pro of same to this office. YES � NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box. INSURANCE AZL BOND ❑ OTHER ❑ (Please Specify) (Expiration Date Estimated Value of Electrical Work$ 6J-�"t30 Work to Start_ &fa 9-10-Q-00 Inspection Date Requested: Rough Final Signed under the pen es of perjury: _ FIRM NAME C�/ril �.✓1I>`c LIC. NO.6--37`/3.;'- Licensee `'� t�g- n4iture LIC. NO.3V q>a Address !!0 to n /�/ dIdpyi— Bus.Tel. No. `C��Q 7� 4??U Alt. Tel. No. - ?d' �'�� 6 a OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or its substantial equivale� as required by Massachusetts General Laws,and that my signature on this permit application waives this requirement. Owner ❑ Agent ❑ (please check one) Telephone No. PERMIT FEES (Signature of Owner or Agent) FORM 18922(FPR11-RULE 8)A.M.SULKIN CO..BOSTON,MA Date.... /... ... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;�SS�cHusE' This certifies that �/ G.....f-- `c . .. ..... ..... // ... has permission to perform ......./.....v.�...... ........... u....(.. ................... wiring in the building of........./.tu �'�..1`..�c...1 ..5.. ... .. . ......................................... a:6....(-;q.... f... .X91.��z�,/ ............... rth7And7Iiir� '2 .` ` `......... Lic.No� .l.�-�...... . . LECTRICAL INSPECMR Check # 01 46Lo TIZECOABIONWEALTHOFMASSACHUSEM 21c ZUs oni DEPAR1AAM'0FPUM1CS9FMY Permit No. Vy BOARDOFFIREPREVEMONREGUZATlONSR7CtM]2,VD Occupancy&Fes eck d APPLICA TT0N FOR PEI'1VHT TO PE'RFO. J?ff ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION). Date Town of North Andover To the Inspector Of Wires: The undersigned applies for a permit to perform the elect 'cal work describ d below. Location(Street&Number) Owner or Tenant ' Owner's Address S Is this permit in conjunction with a b ilding permit: Yes M No r (Check Appropriate Box) Purpose of Building 6b l � ���(� Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. of Meters New Service Amps ! Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work n No.of Lighting Outlets No.of Hot Tubs of Transformers Total No.of Lighting Fixtures Swimming Pool Above Below KVA Generators KVA 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 No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons — Vo.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices 7o.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices 'o.of Dryers Heating Devices KW Local Municipal Other o.of Water Heaters KW No.of No.of Connections +4 Si2ns I Bailasis x Hydro Masstsge Tubs No.of Motors Total HP FIER- ' anceCo Ptnsirrntbtheregtritanaltsof Ga>etatLaws :aamartLiabl7ityhmaar>ce mch>drt�(mficg Coerdgeori;.ssubstnUoquivalaY YES NO ;subrnk-dvalidptoofof to theOlfim YES E0 ff)Doha%edredmdYES,pkmirdcaiethetypeofco - � o�el RANc-� BOND [� orll x Q / 3/ Gb EstffW"ValleofE1Wacal Wolk$ tOStalt hqDeclimDdeReTessed Roo F>rlal h rKla- el ofperjury. C �� IicawNo. U J Sigrnhue txet eNo CIA t 1 h Nkd Ilk Lff', BusirmTel No. AIL Tel No. R'S WS[JRANCE WAIVER;I am a that the Liam doesnothave inst uarim cowtage orits sul�lantial equivalent as recltmAI Tel No. (3er�eral Laws my ggrtattue on this peu7rit applicatira on waives this qunerr>erit check one) Owner ® Agent Telephone No. PERVITT FEE Signature ot UwDer or Agent - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston; Mass. 02111 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 rry 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 or.a fine up to s1,sw.00 and/or one years'imprisonments weU_as_ciyfl.penatties in-thelormxfa-STOP VYDW 0PXEP and a.fine_of.(31110.OD)Ajdw mgainst-me; I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for overage verification. /do hereby cerffiy under the pains and penalties of perjury that the information provided above its true and correct. Signature Date Print name Pbooe.# Official use only do not write in this area to be completed by city or town afficiar City or Town PermWLicensing Building Dept ElCheck if immediate response is req)red E1 licensing Board E] Selectman's Office Contact person: Phone# F-1 Health Department El Other Date..... .................... NOR'rh TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS�CMUS� This certifies that .,—, .............. ...... has permission to perform ..........: ................�........................ wiring in the building of........ ..... .................................................. at.r�'.1�... ..... . ...... f..r.................. ,North Andover,Mass. 44� Fee. .......... ic.No.�/........... .................................................. ELECTRICAL INSPECTOR Check # �94 C.. 5185 COrstmm�waQr(h o`///Cdlat/uc�a�! For Office Use Only (Rev.11/99) r Permitt Number: 1JsParintant a`�irs�awicae .. ,.�� Occupancy&Fee BOARD OF FIRE PREVENTION REGULATIONS f APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:00) PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: City or Town of: A ANDOVER 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) ta�— Owner or Tenant: Owner's Address: Is this permit in conjunction with a Building Permit? Yes ❑ No W--.,'(Check Appropriate Box) Purpose of Building: Utility Authorization#: --- Existing Service: Amps / 14, Volts Overhead �� Underground.13 #of Meters New Service:. Amps / Volts Overhead ❑ Underground.❑ #of Meters: Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work—T/T4,F I/ No,of Recessed Fixtures No.of Cell.-Susp.(Paddle)Fans No. of Transformers Total KVA No.Of Lighting Outlets No, of Hot Tubs Generators M/q No. of Lighting Fixtures Swimming Pool: Above ground n In Ground ❑ #of Emergency Lighting Ba ery Units No.of Receptacle Outlets No. of Oil Burners Fire Alarms #of Zones #of Detection&Initiatin Devices No.of Switches No.of Gas Burners #of Sounding Devices• #of Self Contained No.of Ranges DetedioNSounding evice' 9 No. of Air Conditioners TOTAL TONS: • Local❑ Munl al Connection❑ Other ❑ No. of Waste DisposalsHaet Pump Totals: Security Syste s: Number. NS: KW: No.of Device or Equivalent No.of Dishwashers Space/Area H ting: KW Data Wirin ,No.of Devices or Equivalent: No.of Dryers Heating Appliances KW Teieco unications Wiring:No of Devices or Equiv nt: No. of Water Heaters KW No. of Signs: #of Ballasts: OTHER; #of Hydro Massage Tubs No. of Motors_L_Total HP �aL INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the license v including Y e provides proof of liability insurance d ng"completed operation"coverage or Its substantial equiv lent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE t7BOND ❑ OTHER ❑ Please specify: Estimated Value of Electrical Work$ (When required by municipal policy) Work to Start: _ Inspections to be requested in accordance with MEC Rule 10,and upon completion. certify,under the pains and penalties of perjury,that the Information on this application is true and complete. Firm Name: 1` G� LIC.#� Licensee:���j f� �eC. Signature: LIG.# 16, /� (!f a/ppplicable,enter"exemp"bin the/license numberfine) / q Address: t"Y' Bus.T8175 Y / Alt.Tel.# 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 o OR Agent❑ Signature of Owner/Agent: Telephone# 7A-77;o PERhIIT FEE:S