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HomeMy WebLinkAboutMiscellaneous - 70 QUAIL RUN LANE 4/30/2018Date.2145 ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that'i0 -7 ........... has permission to perform ........ . ...................................................... . . ......... ................. wiring in the building of...,.,,. i ......... .. 1� . -% .. e-- ................................................. ....... ................ ..... . ....... at .4 .) ........ ....... A�� *PC ) ................ . North Andover, Mass., ...... ..... .. ... .. ................................ Fee, lic. No.N-2 .. ................. ............ a ......... /:.."`.'........ ELECTRICAL INSPECTOR / Check., lV C.onrnu►nweat o�lllu�uefs Official Use Only Permit No. �ol_-�-m sewkt Occupancy and Fee Chec iced BOARD OF FIRE PREVENTION REGULATIONS Otty,1107j eave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .All work to be pafonved in accordance with the Mvisachusm Electrical Cods; (MEC}, 327 CMR I2-00 (PL WEPRI ff B V M OR nWT EALL INFO TION] . Date: / City or Town of: �rfh /frac aver To the ICtor of Fres: By this application the tragi, notice of iii or her ifft1 1' to per�nn tate electrical wo& described below Location (Street & Number) '70 Qua l l Ku n Rd Owner orTenant Owner's Address Is this permit in conjunction with a bmldiug permit': Yes [ _ Purpose of Bonding 9 -es Ord ❑ Untigrd ❑ Overhead ❑ Undgrvi L] Telepbone No. No [f ((3heck Appropriate Box) Utility Authozi a ion No, Existing Service Amps 1 vans Mew Service Amps v*ft Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. ofMeters No. of Meters I r-mmhakn afdr followhwrable mvbe waived by the ImPeaOr off m_ = arnica a9MU"0TRU C.esw. 9 — 6-r--- Fstirnated Value of Electrical Workc (When required by municipal Policy.) Work Start Inspections to be requested in acce with NEC Rule 10, and upon ooa►pletion INSUggNCE COVERAGE: Unless waived by the.owner, no permit forthe performance of electrical work: may issue toile the licensee provides proofof Gabriity hwaamce includes "oomplesed operation" coverage or us substantial equivalent- lie undersigned certifies that suchrn,Qe is in farce, and has exbibited proof of same to the permit issuing office- CAECK ONE- WQTJDAWM l7f BOND ❑ OTHER ❑ (Spceffy-) 7� I csrtifp, u>lderthe . and penalties ofp�rtry, chat the info>matro n this ration is true and ew rlete. ` �, FIRM NAME: ima f A !. / t LIG NO.: Id -1 6 _ Licensee: --,rn fG` flt' �%S _ � LIC. NO.: a'StB ;J 1 •j appjrcob/t, enter' ewmpt" is Se' license nwnber rme j Sus. TeL No.% �-' Address: g T : 1 .e0 J�' A1t.,TeL No.:r=5r~���Z *Per KG.L. c. 147, s. 57-61, security work requiresof Public Safety" S" License: Lic. No. - - OWNF.R'S INSURANCE WAIVER: I an aware that the censer does not have the EabtTity insurance coverage normally required by law- By my sieXwure below, I havby waive req°1rement. I am the (check oue) 0 owner owa�'s eat. Owniffm9pat pER1KIT'FE • $ : �� Sigma tore - - Telephone No. --- F� o, of Total No. of Recessed Leminalres a No. of Ce&- (P rmers ICVA No. of Luminave Onfiets No. of Hot Tubs Generators "JJ, KVA N of Luminaires Above In- Swimming Pool ❑ d_ ❑ o• e�c9 $e Ups No. of Receptacle ontiefs No. of Oil limners FIRE ALARMS of Zones No. of and Detection Nax of Switches No of Cas Burners hildlating Di No. of Ranges o. of Air Cond. � a of Alerting Devicrs No. of Wasm Disposers o1. omb_ oar et of Soni' -Con �� ❑ Counech-aml ❑ (law No- of Dishwashers Spaee/4rea Heating ItVV No. of Dryers HeatingApplmnces 1CW f -� or t N&6 Data Wrrmg: No. of Devices or eat No. of H�r� KW o, of Naasts Sizas Ballasts No. Hydromassage Bathtubs No. of Motors Total IIP No. OTHER: _ ,�__� u _t rr�r :_ .,r .. .n,�ned hn lbo Invp-cter of ilrfres arnica a9MU"0TRU C.esw. 9 — 6-r--- Fstirnated Value of Electrical Workc (When required by municipal Policy.) Work Start Inspections to be requested in acce with NEC Rule 10, and upon ooa►pletion INSUggNCE COVERAGE: Unless waived by the.owner, no permit forthe performance of electrical work: may issue toile the licensee provides proofof Gabriity hwaamce includes "oomplesed operation" coverage or us substantial equivalent- lie undersigned certifies that suchrn,Qe is in farce, and has exbibited proof of same to the permit issuing office- CAECK ONE- WQTJDAWM l7f BOND ❑ OTHER ❑ (Spceffy-) 7� I csrtifp, u>lderthe . and penalties ofp�rtry, chat the info>matro n this ration is true and ew rlete. ` �, FIRM NAME: ima f A !. / t LIG NO.: Id -1 6 _ Licensee: --,rn fG` flt' �%S _ � LIC. NO.: a'StB ;J 1 •j appjrcob/t, enter' ewmpt" is Se' license nwnber rme j Sus. TeL No.% �-' Address: g T : 1 .e0 J�' A1t.,TeL No.:r=5r~���Z *Per KG.L. c. 147, s. 57-61, security work requiresof Public Safety" S" License: Lic. No. - - OWNF.R'S INSURANCE WAIVER: I an aware that the censer does not have the EabtTity insurance coverage normally required by law- By my sieXwure below, I havby waive req°1rement. I am the (check oue) 0 owner owa�'s eat. Owniffm9pat pER1KIT'FE • $ : �� Sigma tore - - Telephone No. lk� In ff &I I I The Commonwealth of Massachusetts Department of Industrial Accidents h r Office of Investigations w ' I Congress Street, Suite 100 Boston, MA 02114-2017 ,o www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): BARROS COMPANIES INC. Address: 164 EAST STREET City/State/Zip: FOXBORO, MA 02035 Phone #: 508-543-5118 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑■ I am a employer with 19 4. ❑ I am a general contractor and 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 working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.* 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] S. ❑ Demolition 9. ❑ Building addition 10. X Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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.S. GILMORE INSURANCE Policy # or Self -ins. Lic. #: 08WECCS0341 Expiration Date: 12-31-15 Job Site Address: � %()�� L� -um & City/State/Zip: IVIgVAOJI/Ge 1M) Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration At�). 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 her certify under the painsand penalties of perjury that the information provided above is true and correct. Phone #: 508-543-5118 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 #: 11 State of Rhode Island and Providence Plantations Rhode Island Department of Labor and Training ELECTRICAL JOURNEY EL JOHN K BARROS 164 EAST STRE FOXBORO KA 02 110TIN SKJALK 061qO17016 Administrator Expiration Date- =IVIIVIONWEALTH OF MASSA HUSETT I C'l ANS ISSUES THE FOLLOWI.." t A -------j--0URNEy�M.A ....,,-ILECTRICI Mk t>A ARROS 164 EA 02035-22 248o 0 13601 STATE OF NEW HAMPSHIRE' ELECTRICIANS BOARD NAME: J EXPIRES: z � 44 9006;M MR, NorrN Hw4o✓rte GENERATOR APPLICATION DATE: LOCATION: 7e (�y,���- le -.Uv 'eci /-:�S OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: 05 (�610pr9tii,c-5 /// ( PHONE NUMBER: &-m ELECTRICAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: i77Lrz; / *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) v CONSERVATION APPROVAL Addendum to contract dated 16- G with: Barros Companies 164 East Street Foxboro, MA 02035 508-543-5118 7e oufiiV, 2uk ki o /'l . -' This sheet gives us an approximate on site location for your new GENERAC fully automatic home standby generator. Due to site conditions, we will try to install the generator as close to these parameters/dimensions as possible. But it is possible that the actual installation site may be slightly different than shown below. Accepted by:,t Date: a _, FRONT OF HOUSE Date .... �.aa � ............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that /� �� r .v has permission for gas installation .....-�����.� a �.....,.a, in the building of .......1�-7�'t' %f ........ `Y/r:�`.. C- .................................... at ......70........ � u � I � �...... �M ,., , North Andover, Mass. .......................................... . Fee 0�2.. Lic. No. 3 5�1....&--............................................... �� GASINSPECTOR Check #! iJp:% °� -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE YZZ i PERMIT# iM G JOBSITEADDRESS 2d QtJa^� OWNER'S NAME r GOWNER ADDRESS -�S�j����S_FAX TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUC l AL RESIDENTIAL CLEARLY NEW: F�j RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ,,-=:.TI E:: 1 I I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE �- FRYOLATOR FURNACE GENERATORV GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ..._ POOL HEATER (� R'MM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - - - - - --- -- - .-r �i_ ^ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES ._ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E 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 0 AGENT SIGNATURE OF OWNER OR AGENT 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 will be in compliance with allPertipent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. d PLUMBER-GASATTER NAME �_ _ _ LICENSE #[1: S j SIGNATURE MP MGF ED JP ® JGF 0 LPGI CORPORATION ® PARTNERSHIP ®#= LLC COMPANY NAMEI /9'!r4 C iArCG &_ 11ADDRESS�%- CITY 11 STATE�ZIP /9 TEL -_7?r- -3-?6- FAX CELL IL %r 9i I W H O H U W f w � � o a z Oz d� W >- ~ W O w O H a Z a w W w a W O co �+ w co a 0 a a U J F a M � w x w LL rA H O H U a C�7 0 .V ry The Commonwealth ofMassachusetts - Depariment of lndustpinl Accidents Office of Investigations 600 Washington Street .Boston, MA 02111 www.mass.gov/dia Workers' Compensation Ynsurance Affidavit: Builders/Cont°actors/Electrxclans/Phimberg Applicant Information Please Print Legibly Name (Business/organizaiionllndividual): A0, Gl/ e 7 :-, Address: ] 1 �� � -5"—, City/State/Zip: OW Phone #:-22 Are u an employer? Check the appropriate box: Type of project (required): 1. I am a employer with �3 4. ❑ I am a general contractor and I 6, F] New c6nsintciion f employees (fall and/or part time) * have hiredthe sub -contractors 2. ❑ 1 am a sola proprietor or partner listed on the attached sheet. `7• ❑Remodeling ship aud`have no employees These sub -contractors have 8. [] Demolition working forme in any capacity. workers' comp. insurance.9. ❑Building addition [No workers' comp. insurance $. ❑ We area corporation and its reired.] officers have exercised.theix qu1011Eleciricalrepairs or additions 3. [( qu a homeowner doing all work right of exemption per MGL I L ❑ Plumbing repairs or additions myself. Eibworkers' comp. c.152, §1(4), and wehave no 12.QRoofxepairs insurancerecruired.1 employees. [No workers' comp. insurance required.] 13.❑ Other zAny applicantthat checks box#I must also fill outthe section below showingtheir workers' compensationpolicy information. i -Homeowners who submit this affidavit indicating they ti a doing all worM and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheekthis box must attached m additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site in, formation. � � . /I D Insurance Company N Policy # or Self -ins. Lic. #: -S e{% � C� Expiration Date: 3 tl Sr lob Site Address: 26 6 ()&6� iUn fCJA'd —Pity/State/Zip: i Attach a copy of the workers' compensation•polley declaration page (showing the policy number and expiration date). Failure to secure coverage as requkedunder 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 maybe forwarded to the Office of Investigations of the DIA. for insurance coverage -verification. X do ltereby cert& under tliepains and penalties o f perlwy that the information provided above is true and correct. Phone 4: j'-1 jf- 9'.3C— 2(-7,? official use otly..Do not write in this area, to be completed by city or tort official. City or Town: Perminicense ft `I'Z_7 /-y Issuing Authority (circle one): I. Board of Health 2. Building Department 3. 414. own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instruction -_8 Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an ernployee is defined as "...every person tri. the service of another under any conNot of hire,• express orimpH4 oral or written." An employepis defined as "an individual, partnership, association, corporation ox 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 orrepair 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 ofpubhic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented 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 -contractors) name(s), address(es) andphonenumber(s) along with their certificates) 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 au LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 thepermit or license is being requested, not the Department of industrial Accidents. Should you have any questions regarding the Iaw 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 stamp ed or marked by tha city or town may be provided to the applicant as proof that a valid affidavit -is on file .for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orliermit to burn 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: `l;he Conumawealt� ofMasaac�usotts - Dep-aximont of kadusWal .Accidon a Office ofllmstiga#our 6.0 Waftgtan 8fteet BOA011, 021x1. TQL # 61.7-7-2' -4900 @xt 406 ox x-$77•:114 SAFE Revised 5-26-05 FaX # 617-727-7749 �wvc�.x�a�s,gtiv�clia N° 9658 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . This certifies that . has permission to perform . �P �C /�. .� 4. Cb.re.l.VLJQ. �' I ' plumbing in the buildings of ?.� ...................... at .. .. .�� .. �u A-\- . � AA ,�y...... , 7rtt h Andover, Mass. Fee.z..--'.Lic. No.. ZIq.i� . �"1 .... . PLUMBING INSPECTOR Check # z WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Q 1 � " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY r _ MA DATE - PERMIT # JOBSITE ADDRESS L2A)2t� I OWNER'S NAME POWNER ADDRESS '�' _L' TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL QQ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT -9— PLANS SUBMITTED: YES NO� FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 2 1_3 14 8_ 1.__0 11 BATHTUB - CROSS CONNECTION DEVICE _.-.._.J.. ,_.9_ .: .1. €€ DEDICATED SPECIAL WASTE SYSTEM �( DEDICATED GAS/OIL/SAND SYSTEM i ___ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER __.1 DRINKING FOUNTAIN _ i ._.._......1 J .J _.__.._I ^,,.# FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR(INTEMOR) (l ------- ----KITCHEN KITCHENSINK LAVATORYROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL .._____.l - ------ J _..-_-_( __._._ i -_......J ... WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _-' WATER PIPING OTHER _ � _ ._ _`s __ .__ J .._____ i _€ INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND Q 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 ONLY: OW a AGENT Ej SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application ar u accura tot bes m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m ert' is' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. the PLUMBER'S NAME L LICENSE # SIGNATURE CORPORATION -4 PARTNERSHIPO# ; LLC Ek COMPANY NAME i 6PN / ADDRESS - D ��X ��a CITY I STATE 17 I ZIP j —� TEL FAX i CEL. �_ _ !EMAIL LS o� z W 0 - -, 0 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 Legibly Name (Business/Organization/Individual): l V47�L� L� Address: 18r& City/State/Zip: BO� � E W Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions lumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. fain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date: fob Site Address: City/State/Zip: kttach 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 Lfuze up to $1,500.00 an one-year imprisonmen as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to $250.00 a d a inst the violator.advised that a copy of this statement may be forwarded to the Office of nvestigations oft D A9 for insurance co/eraae verification. r do hereby the information provided above is true 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone • V L r0 r' °' -o n ! m m � o r M,a. _. _ O z M.0 ro 0. o z Zr... a. ,o m mr- �; m� O. D c oW Z, a ! s Z D Dm �' m ID r = NN CD D d T. m D r c -i ui m �2 y- < Cz v -?.. O D T1 L D _r iTJ� C) ZD 5. n • 'N o z mcn > ° r< N m �T (n o m 6N Zm J.w r� c cn m 16 I o (n I 1 - - - Si re - - - I pm -w oF3> 0 Fn 'n 0 --q 3:OO z mmwo D DWZC Z -im• z mmi� O D mvmD O m' v-DiOv izo maC Om zi C1 cn z m0 v This certifies that Na-kar.0"I .� has permission for gas installation.. !./r?!' f � � v in the buildings of ..Q1. at ......... 0... ,:/ �'..,�, J..� ` orth Andover, Mass. L _ Fee ."�.. Lic. No.2H GASINSPECTOR Check # X425 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - -# CITY ► t4^ )0VMA DATE r ` PERMITip JOBSITE ADDRESS. I_� �Il S I OWNER'S NAME GOWNER ADDRESS _ --_ - TEL _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E]EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: [ RENOVATION: ® REPLACEMENT: 01 PLANS SUBMITTED: YES El NQ. APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER -- COOK STOVE DIRECT VENT HEATER �I L1� :I r._J �- . -- - DRYER FIREPLACE FRYOLATOR - FURNACE �._ _s 1 L_,_—_� --� --- I ---- - -I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _ _ I--1�- MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER : . - I .. .-._J _ - i.- _ !— _ .._ - .. _ I - --j ROOF TOP UNIT TEST UNIT HEATER _ j { �I UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES §kNO IF YOU 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 L3 AGENT ..._f SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tru an a rate to th es of my kpowle ge and that all plumbing work and installations performed under the permit issued for this application will be in comIia a all Perti a ovision df the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME IJVI'YL M f -p ( LICENSE # 21 _ _ ._ SIGNATURE MP 0 MGF [_-]l JP)2f=46F [ - LPGIpl CORPORATION D# PARTNERSHIP ©#= LLC [J# COMPANY NAME:11�,._ _L�'%�-ADDRESS _------ CITY _ _ --- _ _ L� _ _... [ STATE IP -I TEL L_ _�T _ ./� ..•_�_-rt_— RI FAX �CELL�� i EMAIL ^_ III 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 Leeibly Name (Business/Organization/Individual):��— Address:'�' /7 50Y % g City/State/Zip: B O ^ Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4• ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors Dremployees am a sole proprietor or partner- listed on the attached sheet. t 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.] f employees. [No workers' comp. insurance required. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions lumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *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 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 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 N Policy # or Self -ins. Lic. #: 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 an one-year imprisonmen _as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a d#IaVainst the violator. advised that a copy of this statement may be forwarded to the Office of Investigations oft D A for insurance co eraize veriAcation. 1 do hereby the information provided above is true 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): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4 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 burn 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 j oo -P, > m 7 :T- C%:, 0 0 Z. :E. M-0 U; :'o Z Zr- V) (na, 0. m rn 9 Z. CL 11 > Cl) a (- DO * -n 0 z Fn >M > cn m CL -1 0 U) m > > r— 0 o m 03 > Z CD 0 0 O< ca 0 > m m Z> Mtn > > -u 0 a Z M cr) U) CD =L 0 0 --i > zM 00 U) N U) J 3i Te OmE-o c6 nO-n _MM 0 r-D� m q r- --q 0 Fn S U) R "a -n U) --I -n -.q,30 mCzm m (A cn 13 > U) -q 0 r z >mz m z m 0 I'n caF>z om--io n. >om> M>oz -q z G) xmD m V Ch Om m a j Location �n No. Date 0 NORTN TOWN OF NORTH ANDOVER oat.*�� %* Certificate of Occupancy $ 8 -- 41 } Building/Frame Permit Fee $ J„CMus <� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ g Water Connection Fee $ TOTAL $ `$ Building Inspecto Div. 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C7 W O O yco CL VJ O m y CD 0C � c am: lJ O yam: d N ; • O H O. 01 O' n z _ �• C O — �CL ' j"� y W O t0 rA• (� v, ca -9 o �i � m � m • m Cl O �o O o o o .. o z CD . y 3s G V CD „• 7 = C. o m �: VJ CD O r: C O ; c, c; w: CO3cli_ O W B d " o CrJ d y a G (D o G n rz Ha 0 n? � C r t O ?i n ,vcn C G C 0 b C/) i3 O x O o z O w N3 a Omq 0 0 c MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING _ (Print or Type) lug G 9 y Mass. Date.. ��g Permit #4 _ Building Locatlon_70 (� (%%�- j�, 17(,)(11 -.---Owner's Name_ _ 7Vne of Cir-r�innnry Id/Jn /�% New Renovation ❑ r. Replacement ❑ Plans Submitted: Yes❑ M Instal�lIng Company Name Check one: Certificate # Addrmss mmr3• HE WING Corporation Z P.O. BOX 8880 ❑ Partnership MA 0127T-13UT-- Business Telephone --Q • �- O Firm/Co. Name of Ucensed Plumber or Gas Fitter�� INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IN No ❑ It you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 10 IOWNER'S INSURANCE WAIVER: I am Chapter 142 of the Mass. General Laws, Other type of Indemnity O Bond ❑ aware that the licensee does not have the Insurance coverage required by and that my signature on this permit application waives this requirement. Check one: S!gP1a%Wj_9Wi Owner or Owner's Agent Owner[] Agent ❑ 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 for this appiicatlon will be In compliance with all Pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the General Laws, T e ofUcense: Title Plumber ignature o cens um er or as titer Gaslitter City/Town Master License Number I J'nCMZ Journeyman 6` ae s o- S' no No am=SMEMEN OEM on MENEM NMI 12NO FLOOR OMNI SOON IS No OMNI .. OMNI 11111111 __HFLOOR Mom- 0 1111111111 NMI Instal�lIng Company Name Check one: Certificate # Addrmss mmr3• HE WING Corporation Z P.O. BOX 8880 ❑ Partnership MA 0127T-13UT-- Business Telephone --Q • �- O Firm/Co. Name of Ucensed Plumber or Gas Fitter�� INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IN No ❑ It you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 10 IOWNER'S INSURANCE WAIVER: I am Chapter 142 of the Mass. General Laws, Other type of Indemnity O Bond ❑ aware that the licensee does not have the Insurance coverage required by and that my signature on this permit application waives this requirement. Check one: S!gP1a%Wj_9Wi Owner or Owner's Agent Owner[] Agent ❑ 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 for this appiicatlon will be In compliance with all Pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the General Laws, T e ofUcense: Title Plumber ignature o cens um er or as titer Gaslitter City/Town Master License Number I J'nCMZ Journeyman 6` ae s o- S' No , *T COMMONWEALTH OF MASSACHUSETTS $0, N�c7fY }j» fr'liLn . u r1 n l I; K A N U O tl p T �g} IMPORTANT NOTICf I. ;i,•'x r t I•I i t i n'.i n n', A UUUI<Ng MA �16hul r lif �I',:I�+• I'. �l!I-','; rl IIN I Hii1 QA TO FA, �1�Iv{{�f! ��OtWNI 11 t S 4 IIID AI 11, r ;•1. fI I, luurin:. I; l;n!::NON O NS TA OAnn P(l Il(I/, 1111(,0 `;Al I r1 MA 01971-8860 691784 18597 05/01/96 691794 EXPIRATION DATE SENALNG. I COMMONWEALTH OF MASSACHUSETTS. < i�x.�x f4. -t .. • • r • 1 + t... ,�I .t. •w• Pai •?:: '. a�rrry�}+n BOARD IN PLUMBERS. -AND GASRI -y_n,t-NOTICE: f ,G, r4'it PL LICENSED A S A''•M•A;S-TE R PL M$ t ER PONrbLUMBlflO A11D'Ot ISSUES TRIS LICENSE TO . , - ltp : • `. STALLATIONS ON STATE'OWNE FACILITIES MUST BE FILED AT TH TYPE T FI 011 A S R G A G N O N• OFFICIO THE STATE BOARD. . PO 13OX 8860 SALEM M-4"'1971-8860 691783 10136 05/01/96 691783 yy _ Y 'r I COMMONWEALTH OF MASSACHUSETTS BOARD IN PLUMBERS AND GASFITTERS IMPORTANT NOTICE PL REGISTERED AS A' PLUMBING CORP PERMITS FOR PLUMBINO AND OAS ISSUES THIS LIC NGE TO INSTALLATIONS ON STATE OWNED `` FACILITIES MUST BE FILED AT THE TYPE THOMAS R G A G N O N 1 OFFICE OF THE STATE eonaD. -C PO BOX 8860 SALEM MA''0/1971-8860 674686 1524 05/01/96 674686 COMMONWEM TH DEPARTMENT OF PUBUO SAFETY' lr� of ONE ASHBORTON PLACE MASSACHUSETTS BOSTON, MA 02101 LICENSE cAUTIo ExrmAIION DAII SPRINKLER CONTRACTOR 08/31/199,' EFFECTIVE DATE LIC -NO. FOR PROTECTIO' RF.STRICTIONs THE". PUT RIG, NONE ,�08/31/1993 002265 a PRINT IN APPS xTHOHAS R GAGNON 6 BOX ON LIC LY SWICHIM RO SS d 025-48-6u1f " P A 1938 BLASTINGOPI MUST INCLUD! ''. i-IEIGHil CgLrYgrp p . )8/31/1957 �. •t .• .;`\i` .e(, (,w.f. �EnSOUO. %�ry &a,jo�6WW OM � Mw,uM 4L N/AWV14C✓.. ,Orw(.M%.•ni(Iwiwui.w ir..1 •,.rr,,,� ,f ntrw f,������/' Date . t ,.... ......... . ,kORTR TOWN OF NORTH ANDOVER OFt.,,ao ,e 1M 0 PERMIT FOR GAS INSTALLATION i1 SACEHUSEtAy 1— r_i This certifies that ......:........................... . has permission for gas installation ............................ in the buildings of%......................................... at ....................... c'............ , North Ar}dover, Mass. Fee......... Lic. No.. ' ..... r.............. . .... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Date....... a./............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......-)..!!l../1 _.4...... ...... ................. has permission to perform ..... /� ..... .. ................. .... .............................. wiring in the building of ......... zm/. z ........................... at.... 70 q Yc LA A .................... .. .......................... North Andover, Mass. Fee ./� Lic. Na� ........ 4400� .................. (-7 ELECTRICAL INSPECTOR Check M L' 7 7 rl -Iqs eM&r,��5Xz7W 09 DO -4--d 4 PW& S410 1 BOARD OF FIRE PREVENTION REGULATIONS 527 APPLICATION FOR PERMIT TO PERFORP All work to be performed in accordance with the Massachusetts (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical workdescribedbelow. Location (Street & Number � ),41' (I 2V V Owner or Owner's Is this permit in conjunction with a building Purpose of Building 1 h� 77s Official Use Only Permit No. Total - R 12:00 Occupancy & Fee Che cd L n ELECTRICAL WORK Electrical Code 527 CMR 12:00 Date LgL I W To the Inspector of W' es: Yes 0 No d/(Check Appropriate Box) Existing Service Amps Voits New Service Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Utility Authorization No. Overhead 0 Undgmd 0 No. of Meters_ Overhead 0 Undgmd 0 No. of Meters _ OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = ff ecked S plepse indicate the a of over le by checking the appropriate box. INSURANCE BOND OTHER = (Please Specify) // a (E t (on ate) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Signed under the Penalties of perjury�d C /� A, Y. 7 FIRM NAME . �/� u LIC. NO. A 33 Licensee c>,] I(Ff 1 /I �a i) Ky-% Signature / f/ I�z LIC. NO. Addres� v� �L/ j Bus. Alt Tell No. I ��J'- � OWNER'S INSURANCE WAIVER: I anLagare that the Licen es does not have the insurance coverage or its substantial equivalent as required by Massachusel General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) U _ cl Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Total - No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 No. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishwashers ' Space/Area Heating KW Detection/Sounding Devices 0 Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds _ No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = ff ecked S plepse indicate the a of over le by checking the appropriate box. INSURANCE BOND OTHER = (Please Specify) // a (E t (on ate) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Signed under the Penalties of perjury�d C /� A, Y. 7 FIRM NAME . �/� u LIC. NO. A 33 Licensee c>,] I(Ff 1 /I �a i) Ky-% Signature / f/ I�z LIC. NO. Addres� v� �L/ j Bus. Alt Tell No. I ��J'- � OWNER'S INSURANCE WAIVER: I anLagare that the Licen es does not have the insurance coverage or its substantial equivalent as required by Massachusel General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) U _ cl Telephone No. PERMIT FEE $ (Signature of Owner or Agent) R The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: 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 Ctiv: • Phone.# - Insurance Co. Policy # Company name. Address CiCY Phone* � Failure to secure coverage as required: wider Section 25A or tiita 152 can lead to�the . andlor one years' imprisorwrowt� -cag7.�iesio3hefamn�ta JQP + of criminal Penalties of a�fine up t understand that a copy of this statement may be forwarded to the office of Ir cove �S� t]Oja days° nviesligatiorr3 of the DA for coverage verification. Ida hereby cery w titer pre pains acrd penaMes oiperjwy bW ere i+dorr Om provided ab "rs kw avid correct Signature Date Print name PbWe Official use only do not write in this area to be completed by city or town d)dW City or Town ' CI Badcov ❑check if im xxkate response is required El Selectm, Contact person: Phone ❑ Health C ❑ Other Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................................... has permission to perform ........... ..................... ........................ wiring in the building of ....,.�.%.................���................................... A - W -r ................................... at ...... IP&Aa ............. ........................... North Andover, Mass. Fee.:ft:.ipi�'�9.. Lic.No..A'133........ ELECTRICAL INSPECTOR ; Check # 51,•35 THE COMMONWEALTH OF MASSACHUSETTS DEPARTAI EW OMBIIC SVV Y APPLICA71ONFOR PERMIT TO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE P (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical work Location (Street & Number) Owner or Tenant Owner's Address R CMR12.00 Office Use only Permit No. 3s Occupancy &Fees Checked /�74 � FORMELECTRICAL WO fSSTS ELECTRICAL CODE, 527 CMR 12:00/ 0 Date To the Inspector of Wires: below. Is this permit in conjunction with building permit: Yes,u No LJJ (Check Appropriate Box) rj--- / �2S33 Purpose of Building ��iC QJ ((� `'; j Utility Authorization No. Existing Service Amps�Volts Overhead Underground No. of Meters New Service AmpsVolts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work VT77 77? t/(LP No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round 0 round 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 Pumps 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 Heating Devices KW Connections � No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- h%Ita=Coverage. Ptua>atattattletegtriternatts0fMaMdMMGenaall:aws Ibaveam nalliab1ldylrnt rmwPbbcyin k& gComplete CfitSSubSUMC#Vaifft YES IbaNeahriwdvardpoofofsarnetDftO>Iio-, YES� lf)"AaNeched®dYES,ple cheddnglhe box E INSURANCE BOND r7 OMIER M (Please Spacf'y) f WodctoStatt% DaleReq rod Rough Sigttedtutdert�ieR3tahiesofpetjtay FIRMNAME ��-'J'44 E/ec .� Sime 9� C4 /0� OW OCSINSURANCEWAIVER;IamawareEattheLioatsedo andthatmysigrrMwc)nd»spemritappkationwaivesthistegtt mifft (Please check one) Owner " Agent signature ot Uwner or Agent Eti WdVahrofl~7echicalWcdc$ Fatal LicemeNo. - V", " � W .� ' ""` -- ',AItTUN6. m e the insutame coverage or its substantial egrivalatt as Iegmed by Massad xism General laws Ql� Telephone No. PERMIT FEE $ a,19