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HomeMy WebLinkAboutMiscellaneous - 71 LIBERTY STREET 4/30/2018 (2)0 0 v 0 �i 0 0 0 0 0 U11M Date. ...'7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ 14 ... 6 a ........ .................... ...... .. . ..... ....... Z ............ has permission to perform .... .. ..................................... -511-al-0 !�'T wiring in the building of ....... ./7 ............................. .... . .... ............ at .....7....... /........................... ../ .. ....... . North Andover, �M Fee ..................... Lic. No.............. ... ....................... ..... ELECTRICAL INSPEE OR Check # A IL Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ /P `/, Occupancy and Fee Checked _ :ev. 1/07] (leave blank) _ APPLICATION FOR PERMIT' TO PERFORM ELECTRIC All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 00 WORK (PLEASE PR8 THINK OR TYPE ALL WORW TION City or Town of: NORTH ANDOVER ) Date: By this application the undersTO igned gives notice pf is or her inten ' n to erform the elthe ectrical trical wk dector of escribed below. Location (Street & Number) Owner or Tenant Owner's Address r Telephone No. Is this permit in conjunction with a building permit? yes LJ Purpose of Building 1A ty (Check Appropriate Box) Utility Authorization No. Existing Service Amps /Volts Overhead ❑ Undgrd ❑ No. of Meters NewerCe Amps _ -L __Volts Overhead ❑ Unilgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges ---------------- No, of Waste Disposers ---------------- No. of Dishwashers Vo. of Dryers Heaters KW Hydromassage Bathtubs C'omp[etion of the of Ceil: Susp. (Paddle) Fans Of Hot Tubs Swimming Pool Above rnd. ❑ InT No, of Oil Burgers No. �GasBurners No. of Air Cond, Total HeatNumber T ns ""U" s 1 Totals: - ._ ....... _..._._... Space/Area Heating KW Heating Appliances, Ballasts. o. of Motors Total HP table may be waived by the �...0„ureters KVA Generators KVA o. o mergency tg g ❑ T2..u...�. rr_e... ALARMS INo. of Zones of Alerting Devices tion/Alerting Devices ❑Municipal Connectinn ❑Other No. of Devices or Data Wiring: No. of Devices or No. of Devices or Wires. { Estimated Value of Electrical Work: J lao Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the lieensee.provides proof of liability insurance including "completed operation” coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pain an penalties ofperjury, that the information on this application is true and complete - Licensee: Tete. FIRM NAME: F(e G T!",r C P Licensee: LIC. NO.:42 a �� Signator LIC. NO.: (If applicable, enter "exempt " in the license number line.) Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of public S"Alt Tel No OWNER'S INSURANCE WAIVER: I afety am aware that the Licensee does not have the IS" License: : required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ iability insurance ner coverage o vnero'swent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � f% ELECTRICAL PERMIT NO. INSPECTION REPORT. ELECTRICAL INSPECTOR - IDOUG SMALL ID ...7 f T .0 di1CU — Inspectors' comments: -no 2. FINAL INSP �CC�ION; Passed — [ Failed — [ ] Inspectors' comments: (Inspectors' Signature —_no 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ) Inspectors' comments: (Inspectors' Signature -.no ii 4.'. INSPECTION— SERVICE: - DATE CALLED NATIONAL GRW: Passed — [ ] Failed — [ ) Inspectors' comments: 5. INSPECTION - OTHER: Passed — [) Failed — Inspectors' comments: -no - no initials) ection require(f ($50.00) - is) Date uired (550.001 - Date 7 Date NAME: .-inspection required ($50.00) Date Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND ARE-1NSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of industrial Accidents Office ofinvestigations ..600 Washington Street . Uf Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DDECant Tnfnrmatir,n Dame (Business/Organization/Individual): Address: City/State/Zip: Phone #: e y u an employer? Check the appropriate box: . m a I aemployer with �_ [21:1 4. ❑ I am a general contractor and I employees (full and/or part-time).* I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. I ship and have no employees These sub=contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work myself. [No workers' comp. right of exemption per MGL c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] ;, -ny appE ant the t checks box 4l must t 11 ,u t f si a sm out the section below, showinb :heir woMecs' cc m = H Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Rcofrepairs 13. ❑ Other omeowmers who submit this affidavit indicating they are doing all work and then hire outside contractors submit must sumit 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. policyinformation. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: ��� �� /' !/V► Policy # or Self -ins. Lic. #: ` /I Expiration Date: Job Site Address: 7 41(er T y .�' � N City/State/Zip: �v-t- � 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 cern, un ains and penalties of perjury that the information provided above is bue and correct Si ature --/ 7 � 0(1/... 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 Insp 6. Other ector 5. PIumbing Inspector Contact Person: Phone #: f a` yN � c ro N _ N os O C O�- U TT Tp p p O� y � � N 'oma caa�oo�a� 4 N N O O 4 N L N C 1 '� O soa ��Qov = iny� '4 OQ«y�c6 p N C N O c6 O N c4 -O � w � D3 J N O 00, O EC..`. y .. N m Nam E C Q N N a� 4. C C � O p z U COT C U N C Q _ O r ''' R N O ci N'y0 00 C:N(C�N Lo 6 (11 t ... a - f co do I= :. w ti U Fr- co N t 4 U o LL F .. p:. q o _ Q a 1 ix U w 2 ,� C>) k� '• CCW IUWwA o A Uw w.� o IZu,L.W . o a LU co >- 3 LL • U) - cD. Zr z, a o - ¢ o o I; wrr a~~ Z N CC z. H t Location / No. szz_ Date NORT1y Igs— TOTAL 10/30/95 14:47 _. 92,76 (Q $ Building Inspector 40.0o PAID Div. Public Works TOWN OF NORTH ANDOVER O.tt�ao ,a +,ya p Certificate of Occupancy $ air Mr Building/Frame Permit Fee $ 2c) Z0 cHuSEt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 10/30/95 14:47 _. 92,76 (Q $ Building Inspector 40.0o PAID Div. 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SIDE -A 0` REAR !30 11S 140T LOCATED A �,j E:.3- IIAB 1 IS I it, D 0 $1� - CE.IRT1 FIE D PLOT P.LAN A R E.1 J/Q��'r'` AS PRE 'PARED FOR. tAUL 0'44 F. R VA 'yidMARUIGNICA . SCALB DATE MA Y I I Ah I ILI D Uth-�4�,;�,r' MARCHIONDA ASSOC., INC. A� 1, PLkN,*",Llq(; CONSUL-jvas 60 RAPU ,3iRITT 16 P. E.14A,*3. 02150 �M ��ic UAA RESTM NH 03103.: 4"0-6121 ­­­.- (603) 434-8725 LAA� Town of North Andover 4 HORTM i 6. OFFICE OF 32 0 �o c COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street a KENNETH R. MAHONY North Andover, Massachusetts 01845 9SSnc►+us�t Director (508) 688-9533 Please print. DATE 2Ce l S JOB LOCATION 71 Le HCMEOWNER LICENSE E.=MPTION s61�� Zl/- Numb//er / Street /adddress Section of town "HOMEOWNER" /�C �lC /LO l�L1 /U �� �J.255_2? Name Home phone Work phone PRESENT MAILING ADDRESS 7� v City/Town State Zip code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Sec- tion 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he: she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes. by-laws. rules and regulations. The undersigned "homeowner" certifies that heishe understands the Town of vo. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. /7 HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 3,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control. BOARD OF APPEALS 688-9541 BUIMING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D. Robert Nioetts Micbae! Howard Sandra Starr Kathleen Bradley Colwell TOWN of NORTH ANDOVER AFFIDAVIT L•n- nl• • a13 1 • I■r. • 1(6 3• 1 1 1 - 3•• . ■ • • IFE- ■ • 3 • : ! • 30:1 1011••c• 1 Vz.111re •• swY • 1110 • :113I I it:11• •zil• ! •Ingo 806161r:4 . 1 • • •• Y.1 1 • .I • • I • 11 �: - 1 • • - 1 1 • I• ■ 1 1 • .I - . • . •3 1• Rat3.Y •3 •' • •1 •1 •- •• 1•A 1 1 •3 .1 3i••3•!• • N 1 •1 �• 1 Type of Work: Est. Costs Op Address of Work -7/ lam' Z:) Y A 4,z -y c Owner Name: 0 n Date of Permit Application: 0G#'4- / 9S I hereby certify that: Registration is not required for the following reason(s): For office Lige Only Work excluded by law Rpt ND. ,Lob under $1,000 Date Building not owner -occupied 1;7`—Owner Pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIIt OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS -.- FOR APPLICABLE HOME DffWfE R9T WORK DO NOT HAVE ACCESS TO THE ARBITRA- TION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed Marler penalties of perjury: I hereby apply for a permit as the agent of the owner: oC'/ as Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:, Date caner Nam 0 cn 0 42 cnaaiwv Mwwwo cn > WwLI.iZ: ca AZ 6" rn cz cn —,< .oz.s -< F 0 j- co 0z-Z,- ,6'46: cnz <WO NZ u 0 a, Ic 0 co z cn Q z to E Z Ln 7 is kn z a to O Lu '9 0 c) ID "1 2 L-d . fn tq LV0 o k4 N 0 -C o o 0 z 0 40 Q <m a W LL x x 0 0 Location-- 1 No. Date 8556 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation ' Fee $ Other Permit F pa $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 9) $ Building Inspector Div. Public Works 0 Ir M a Z N F a U) W w < i O z Z < 0 a Z < 0 a a u F W Q W W F U z z u U) I U W a U) Z I � Z Le 0 C w O U O W 0 W 1 W 0 < '. 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A4 0 E-� W L) �o Cn 9A AwwaW,a q A V} x v) :l E -•r W xHHxv)x 0 Y ... a0Aa�a oa�Az� V)z�-< �VEV) t3W x ,- >"HCOz°COA O M O � � a 0 0q �1c.1c°vNaWUAr0 0 0000 p NcJNcvNN C� O Q qc a pa V A tsW LL W WWzOO qE-4FrAA 1 AMco !x 15''x q8" OVECROUND POOL NAP-k-5K0QUPVCA M 1 ROg L APV,4 690RUPI,4A 7/ Li bP-rAl 64ree,�' NAP BLOCK 0166 Book 0364 `: ti U u i Date. /--, ..7..... c+ f NORTH TOWN OF NORTH ANDOVER g .e.° •O 9 PERMIT FOR GAS INSTALLATION .A' This certifies that .IV* d -'A% -.< ... ? .................. has permission for gas installation . ��� �! .� .. t�q 'N ..... o in the buildings of%?'�f%eh ..S4 �. v P/T................. . at . 71... � /,4. t.............. , North Andover, Mass. Fee .; ., . � .. Lic. No.P' . :..... . GAS INSPECTO WHITE: Applicant CANARY: Building Upt. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date 1 g -,Z Permit #� d Building Location 7/ L/ 7` S7" Owner's Name 00 Type of Occupancy New ❑ Renovation Replacement ❑ Plans Submitted: Yes❑ No �( Installing Company Name y 1 A*r Check one: Certificate Address /�/o .SCP Corporation A) 3 <�' ,L,ZGn ' /`% ❑ Partnership Business Telephone KO R' 77S/- x760 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter �✓f�-U'd� &A,. .o I S INSURANCE COVERAGE: I have a current)lability 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 coverage by checking the appropriate box. A liability insurance policy, Other type of Indemnity ❑ Bond ❑ 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 accur the bes of my knowledge and that all plumbing work and installations performed under the permit issued this application I i all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene By T of License: Plumber gna�'i tura oaf ce um er or as r er Title_ Gasfitter aster License Number . Z 7 LS- City/Town � City/Town Journeyman APPROVED OFFIC 0 L . Y ME MENNEN CM MEMOMEENEENEMEN EM on MINOR rte• • ■��������������������■ ��� .. ■�������������������t�■ Ston Installing Company Name y 1 A*r Check one: Certificate Address /�/o .SCP Corporation A) 3 <�' ,L,ZGn ' /`% ❑ Partnership Business Telephone KO R' 77S/- x760 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter �✓f�-U'd� &A,. .o I S INSURANCE COVERAGE: I have a current)lability 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 coverage by checking the appropriate box. A liability insurance policy, Other type of Indemnity ❑ Bond ❑ 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 accur the bes of my knowledge and that all plumbing work and installations performed under the permit issued this application I i all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene By T of License: Plumber gna�'i tura oaf ce um er or as r er Title_ Gasfitter aster License Number . Z 7 LS- City/Town � City/Town Journeyman APPROVED OFFIC 0 L Location T,I C i Date�— . f TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 'E� jQnNTPermit Fee $ OtrhH�r�etrtYflt Fee $ APR 1419! Connection Fee $ Water Connection Fee,, $ NO. Ando Water $ , '3o, Building Inspector Div. Public Works G CJ NW 0 s O Z N vc X W O3 c Z O Z m IL N Z 0m ILL O V W N Aw dJ L! Z N a IL N W 0 N LLO i m N O F W W a m N E F O a 4 0 W N N 0 ,d m I- 1 W d o ►\ W 0 0 z g z Z N 8 m �"� OL M 0 d�o I J WW a i: <U 0 S W z J � L L 0 N L .Q z L u W 0 Q W N Ir u) W i d Z 0 c/1 w Z O i Z 0 <N 0 0 O r a W Z < u N W z N W z W ~ u Vm u m 0 0 <\ ® ,V 2 W Q• o m u al N < N N J J w LL 0 N z 0 N z < i d O N N F N d w W W C F N F 0 m LL W u z U) N N K W 0 K C W C N W I N W _Z J f- 0 J E 0 Ix LL W u z N 0 x 17 Z f 0 0 LL LL 0 W N N z .J 0 m 1 0 0 z z N 8 m M 0 x WW � i: <U 0 W J � L L F u z IL u W 0 N z v d Z 0 W O Z 0 IL 0 0 a g L Vm u m ® ,V 2 W Q• o m u O N < N W> 0 0 0 W Z p F i C > N o ° J I L 0 0 0 m 0 C z z Z .J m 1 N 0 x i: <U 0 J � W u 6 N W z N z Z 0 W O Z 0 a o ^1 Vm ® ,V 2 W Q• O N < N W> 0 0 0 W Z F i C > N o ° d 0 Z W2 u IPWI z m aZ 0 O F, < f o i w A Z N N LL N W I -a W < C 0 O 0 m a O m � F O m 0 I- a a U W i J :� 0 m _ "' u N '.2 IL W W u < W z 0 N a d W < a 0 m T. 0 C z z Z M m A O M v Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE Ao:.,Z "7 / R q 2 U JOB LOCATION Number Street :'HOMEOWNER" Ma < f kort"( fikQ Name Home PRESENT MAILING ADDRESS C. � 5-f- SW ,-A - ,ress Section o S©(f) 682 5-t 32 one Wor one town lyd-�-Zi v Oze4 City Town State Zip code The current exemption for "homeowners" was extended to include owner occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use acid/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building'Department minimum inspection procedures and requirements and that he/she will com ly with said procedures and requirements. ,HOMEOWNER'S SIGNATURE .APPROVAL OF BUILDING OFFIC Note: Three family dwellings 35,000 cubic feet, or,rger, wi be required to comply with State Building Code Sectio 127.0, struction Control. FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) t PERMANENT ADDRESS ASSIGNED BY D.P.W. STREET I I L i h 0;4ZA Cc% APPLICANT Q 5LooAv)Lnz PHONE �;82 5 DATE OF APPLICATION & (� p-�p-- t -7 , t Q 9 2 TOWN USE BELOW TH1S L1NE PLANNING BOARD TOWN PLANNER CONSERVATION COMMISSION CONSERVATION ADMIN. B OF HEALTH HEALTH SANIT 9 DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. DA'Z'E APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPIM'.D DATE REJECTED RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health 1loards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. LP O J J 3 W ^ III ni D r n. c f: r w 0 3 0 Fmq *�I O z 2 rc a. F— ui 1 D Q C o C C6 � � CL •� 'O s c Q V = F W W C9 O N Z Z Z W °' W p O V Vf W o z z u oc oe p m u L m m C u V o L E J L o. R W L L Y o Z) c. c co a: U ii a: U. a: CO ii ¢ ii m D Q C C C6 � � CL •� 'O s c 0O O C6 d `c 'C '> = F c o c z O f+d ;z :z :p N O Z Date........ .......................... 2401 ORTH 0 *,-to TOWN OF NORTH ANDOVER 0 I -p PERMIT FOR WIRING ,SSACMu Thiscertifies that ....... ........................ .................... I ................................ has permission to perform ....................... ........................................................ . wiring in the building of ................. .............. ............. . ................... ... Lo at ... b ...... ... ................... ........ ".1 . .......................... . North Andover, Mass. Fee ..................... Lic. No..........,... 4 .. . ............. ....... a14- 41-01 EOCTRICAL INSPECfbR — I WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File The Comm.onwealth Of Massachusetts °"iCe Use °"l Deparfmcrif of Public Safcty Permit 10. BOARD OF FIRE PREVENTION REGULATIONS S27 CMR1200 Occupancy s fee Checked 3/90 cleave blank) APPLICATION tobe FOR mPed iERordance with �MIT TOPERFORM ELECTRICAL WORK All wmrk Maasachu:ens Electrical Code, S27 CMR 12:00 (PLEASE PRINT IN DM OR TYPE ALL INF0Rtit1_TI0N) Date City or Town of lloeave=-1 To the Inspector of Wires: The undersigned applies for a permit/to perform the electrical work described below. Location (Street & Number) 71 Owner o /,,-/1 Owner's Address Z_,/ dye Is this permit in conjunction with a building permit: Yes Q No ❑ (Check Appropriate Box_ ) Purpose of Building ��'i n� Q L �i�iz,, AyC Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Ho" Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No, of Lighting Outlets No. of Lighting Fixtures No. of Hot Iubs Swiing Pool Above In- mm grnd. grnd. ❑ No. of Transformers Total RVA Generators RVA No. of Receptacle Outlets No. of Oil Burners INo: of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices No. of RangesNo. of Air Cond. Total tons No. of Disposals No. of Heat Iotal Total Pum s Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW _ Local ❑ Municipal Other Connection❑ No. of Water Beaters KW l Sinsf No. of Ballasts LowWirVoltage ng No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current. L lity Insurance Policy including Completed Operations Coverage or it ubstaatial equivalent. YEp I have submitted valid proof of same to this office. YES ®' p C] If you have checked. YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER (Please Specify) 3 G Estimated Value of Electrical Work $ d�j� xpi ation Date Work to Start Inspection Date Requested: Rough Ull L G C �Fi al Signed under te penalties of perjury: , FIRM NAtIE %�� G' 7 - a6l, � tet'!/ G GTl G LIC. N0. /k.1I Licensee �( d �n%� �oCliy9�(% Signature %j LIC. NO. Address 9 �'7 �`/� Es s-; L Bus. Tel. No. Alt. Tel. No. & JV 7- 77/ G OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. 0w'ner Agent (Please check one) I- �=� 3 5. J w 3 J —60 v �.. X � J •SLS ________ SIE IEE :IE ----------M«----- -------- r_N—_MM--------------- i IEI :E! ------------------------------------------------- ! ill IEE -------- ---------- IEI IEE (A �IIE Il! J —60 v �.. X � J •SLS V 7n L I BEE I Y J I Ktt