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HomeMy WebLinkAboutMiscellaneous - 826 DALE STREET 4/30/2018 (2)Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for allation. cj 4!-,r 7D I ...................... in the buildings of e;. . at . . . .5 Z 5.. >�, �� - ..... , North Andover, Mass. 6 00 Fee ..... Lic. No. .................... ... GASINSPECTOR Check# 8491 P - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I 2�2 CITY MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME GOWNER 5A& — ADDRESS — TEL X TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: D RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO 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 DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE � f I have a liabili insurance its current policy or substantial equivalent which meets the requirements of MGL. Ch. 142 YES Cj` O ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG Y 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are ru and accurate to th est of my know dge and that all plumbing work and installations performed under the permit issued for this application will be in c mpl an 11 P in provision of t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # l�l� SIGNATURE MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPA Y NAM �/ ADDRESS��a%��J CITY STATE�o ZIP -6 EMAIL J) 41P--Jt&--j uv-,T-� 2-.�kZAI 2- d,4(je-, ��r 4 4-, w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Apt 6141:�7 9 -(Dl -,L Address: City/Stat 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 2. ❑ I 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.— orkers' comp. insurance. [No workers' comp. insurance 5• V" We are a corporation and its required.] officers have exercised their 3. E] 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 11.❑ 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name: :)licy # or Self -ins. Lic. #: lb Site Address Expiration Date: City/State/Zip: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to Hereby, ce ify unrl r t pa' s n pefialties o perjt that the information provided above is true and correct. % nature: Date: / C:;L 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 ,c. 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 homeowner 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 4 617-727-7749 evised 5-26-05 WWW_mass.anv/dia i - DATE: �Z- LOCATION: OWNERS NAME: I/P_-�IlAW1evo-A' GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: I� a ELECTRICAL RESIDENTIAL , 9fr-, 4 3-7z )-153d GAS COMMERCIAL LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL pq6v,�- TEMPORARY TDEC0A MONWFQLW 0FMMSSACHUSETTS office Use only DEPAR7MFVI'0FPUX1CS4FEIY BOARDOFFMEPREVEMONREGU 4770NSS27C11M12.-1p Permit No. (o J Occupancy & Fees Checked ! APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WO RK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) r 2, f�— Date `9 — Town of North Andover The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wires: Location (Street & Number)"2 N 5 Owner or Tenant 0 Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building Existing Utility Authorization No. New Service Service Amps / Volts Overhead M Underground M No. of Meters M Underground ED Amps Volts g No. of Meters Number of Feeders and Ampacity Overhead Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above EBelow KVA Generators KVA round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets _ U No. of Gas Bumers r*R�g� No. of Air Conti. Total FIRE ALARMS y' Tons N-61 thsposals No. of Heat Total No. of Zones Total No. of Detection and Pum s Tons No. of Dishwashers < Space Area Heating VW Initiatin Devices No. ofSounding ��. KW g ounding Devices No. of Self Contained No. of DryersDetection/Sounding Heating Devices No. of Water Heaters KW Devices KW Local Municipal a Other----� Connections No. of No. of Signs Bailasis o. Hydro Massage Tubs No. of Motors Total HP HER Coverer P1asu<UtothemWitencusof1Vli%m&&wMCaeralLam acuaWLiability hmaartoePolicy inckdTConvew apwris Corwworitssift ialegttivalaR attn-Akd YES NO a Valid ptoofof=r10ftOffioe YESS dr box. ffyai have cfiedod YES, Please indicate the type ofeoveraW by *PME, BOND r7 (P1ea9e Y) tEXpiralimJ)* Start D&RWsbd Rough Estirr aW Valle of BBchical Wodc $ �to tiridel•Tranamesofliajuiy. Fir>a! NAME / � IicenseNo. AV 16,34- /%/T� Signaaae 15—Z's«� 57 er B>$tessTelNo. _97 r 6r'Z / 0IN6 - L� S INSURANCE WAIVER; I Ak Tel No. 7 3 ") :5- - 7 3 — am aware that the Licerm does nothave the jujrarm covt� arks SlIb6lantlal mysigtlaW on this pwnk applir�iori waives oris mgtlrtarta�[ e#� as b'MamAMM CalelW Laws e check one) Owner M Agent El Telephone No. PERMIT FEE $ 1gna ure of Owner or Agent Location No. Date 3 Y-0 TOWN OF NORTH ANDOVER 0 0 Certificate Occupancy $ of 14US Building/Frame Permit Fee $ do Foundation Permit Fee $ Other Permit Fee $ TOTAL $ G?C) Check # 18 5 8 Buildir�6 r6spector •ii TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT ME!�Mj RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING VEC h ; r BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: tqTo Map Number Parcel Num 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage R 1.6 BUILDING SETBACKS R Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided —+ 1.7 Water Supply MG.L.C.40. 34) 1.3. Flood Zane Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIiIP/AUTHORIZED AGENT ' sti ! C?: "I/c; No 2.1 Owner of Record ,pame (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: i Si ature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address _Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone f SECTION 4 - WORIORS COMPENSATION (M.G.L C 152 f 2546) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building r!!!it. Si ed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Descrl tion of Proposed Work cLecka6 appocaw New Construction ❑ — Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ _Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS OFFICIAL USE ONLY Item Estimated Cost (Dollar) to be Com leted by perrmt app licant ; 1. Building (a) Building Permit Fee ®� © Multiplier '202 Electrical (b) Estimated Total Cost of Construction 3 Plumb Building Permit fee (a) x M 4 Mechanical HVAC 5 Fire Protection Check Number 6 Total 1+2+3+4+5 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN t)WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as owner/Authorized Agent of subject property to act on Hereby authorize My behalf, in all matters relative to work authorized by this building permit application. Date �imiafitre Of OWIIer s V SECTION 7b OWNER/AUTHORIZED AGENT DECLAKAI WS F as Owner/Authorized Agent of subject I, property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ture of Owner/Agent Date 0. OF STORIES SIZE BASEMENT OR SLAB 3 SIZE OF FLOOR TIIviBERS 1 2' ) SPAN DIMENSIONS OF SILLS DIlv1ENSIONS OF POSTS DIlvIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) �e�� Signature of Permit Applicant 3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NoRTq TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street D \ ,;;.e��` �* North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner HOMEOWNER LICENSE EXEMPTION Please print DATE: 3//%/-05 —r— Telephone (978) 688-95454 Fax (978)688-9542 JOB LOCATION: Sd 6 0 Al I iNJA Number Street Address Map/Lot HOMEOWNE',)t Ile gez*/&-/ Name Home Phone Work Phone PRESENT MAILING ADDRESS lz�, City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two 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 108.3.5.1) 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 or two family structures. A person who constructs more that one home, in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances 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 comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL. 131).\R1) OF .WPEALS 688-9541 CONSFRVXHON 698-9530 IIF -M A 116RX-9540 PLANNIM.; 68X-9535 CA m m m y m mm v y C � — d COD O CD St z y O. O C2� � Poo O CL y a� o m CD O mCL CD CDo CD mm P C CD y. av y C I C2 CA10 O CD z O CD O CD ,, z W�a =r-1 c c a0 0 x d � o 'coo y L0 tom C'7 ,W Z a.CLO �= 204 MF N T ? d .y d O CD �0 m C o N o.... -♦ IE ro: o x > > ago A R O : r ZAC y C 0.0 a c =ry Li'l a o o L= •• Eor. m O �: x mow CoIrC 1 O o O y �'- 41pt O/ y >> _r N d 01 Q C —4b _ mC. O W d � O d c 0 0 C -F 0► v-0 cl) o o: l �lmop �_ a N � O CD cn7 moo. M-0- 0 -o0 W W omi 0 9 0 c ° ° ° ° ° ° rr S n \ � z o � � W W omi 0 9 0 c Date ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that 1114. ........................ has permission to perform ... 4-. .............. plumbing in the buildings of ... &./�. ................ at ... —/ ........ , North Andover, Mass. 3 r'— I --Lic. ( ......... Fee. . �"7-2 Q PLUMBING INSPECTOR Check # 6378 MASSACHUSETTS UNIFORM APPLICATION FOR (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location .9-� C. A 4 r Owners Name ' of New❑ Renovation ® Replacement Plans TO DO PLUMBING Date 3d A,/ Permit #_ 7 Amount Yes No El FXT'#RES , i ilk --�---.--�..--...--------■ (Print or type) Check one: Certificate Installing Company Name z414 //6ltA.,,/ !J lgir1lf� Corp. Address �a%r S%Z. Partner. Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy IF] Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Pl 'ng Code and Chapter 142 of the General Laws. '7 - By: SignatUrC 01ice�nse Pum er Type of Plumbing License Title VY34 City/Town icense IN um er Master Journeyman APPROVED (OFFICE USE ONLY 1:7� ?- '<-- 0 r -- Date.... ..................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 01 CH This certifies that ............ ....... ....................... has permission to perform ....... hnl-r-.,��r* ..... wiring in the building of ....... . . / ....................... �?2- (,;, at .................. r ........ ...... 5 ...................... . North Andover, Mass. Fee. Lic. Na1q.?%,j4...Px& .................... .. ..... ........... ELEcrRICAL INStECTOR Check # 566 a' TBE C0AM0NTVE4LH0FAS,4CH%,SE'77S Office Use only DEPARTd1ENI'0FPUBIlCS4FM Permit No. � BOARDOFFIREPREVF ONRFGUTAT ONS5270Ml2:(XI Occupancy &Fees Checked APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 l (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Z Vic= s7— To the Inspector of Wires: Owner's Address Is this permit in conjunction with a building permit: YesNo (Check Appropriate Box) Purpose of Building 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 Work7'G.-�sn6E1�=� No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round ED 2round 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 P 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 Si ns Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER i mra=Coverage Ruatantto the regtmanaVsofIvlassactl azaneralLam a Iimeacurrent Liability ki%= Fbhcyincluding C Vied OpwdWm CoNaageorilssubsunrialegttivaifft YESED NO Shaveatbrrmmdvalid proof ofsaw rpthe, Offre YESffyouhaw checked YES, please indicatethe typeofoowrageby INSURANCEBOND r7 OUTER M (Please Specify) B#a6onDa, Estimated Valle dBechkal Wolk $ Work to Start IrspearonDa1eRe4iesled Rough Final Sigrled under r FbAics of Mjtuy: FIRMNAME Licensee � f%� /y G ' Signatiue LioalseNo _ BusinessTUNO. Address_ C� .G 011 `y� /y5 Alt. Tel No. �r7S 37 ;i - T 7 3 OWNER'SINSURANICEWAIVER;IamawarethattheLio wdoesmthawtheinsutatecoweagewitssubstantial4nwlaftasregt>ueclbyMass�GeneralLaws and that my signature cn this permit application wam this mgtmarlalt -ase check one) Owner F-1 Agent Telephone No. PERMIT FEE $ �1 Signature of Uwner or Agent THE COA'MONWE' 9LTHOFAM S94CHUSE77S Office Use only DEPARTMW0FPUX1CS4= Permit No. 4l .S BOARDOFFMPREME?MONROGUL4HONS527C111R121a0 es ,y Occupancy &Fees Checked APPLICATIONFOR PERMIT TO PEIRFORMELE=, CAL 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 The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant 2(o 104zc- s7— To the Inspector of Wires: Owner's Address Is this permit in conjunction with a building permit:, Yes No:. (Check Appropriate Box) Purpose of Building Utility Authorisation No. _ Existing Service Amps / Volts Overhead Underground No. of Meters New Servicer Amps / Volts " Overhead Underground No. of Meters Number of Feeders and Ampacity "•' Location and Nature of Proposed Electrical Work lei nc—oye �-/ No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round lzround No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets d Q No. of Gas Burners FIRE ALARMS No. of Zones o�No. of Ranges / No. of Air Cond. Total Tons No. of Heat Total Total of Disposals No. of Detection and Pumps Tons KW Initialing Devices No. of Sounding Devices No. of Dishwashers / Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal _ Othe No. of Dryers Heating Devices KW Connections a No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP ince(-bmxaW. Pursuant bUlerequffelr=otMasmdus ttsCieneralLaws a curl= LablldykamiceR) yuridrigCmViele OEM= CovwWor&substantial egtrivalent YES NO subnmiedvalidploofofsarrelotheOffice. YES � � 0, ff}alhawdrekeBYES, plemirrlic*the NrofcoNwWby hg the Vprclm& box RANIM a1��JJ(Y> E0n&dVakrofElec"Wblk $ loses IrspectimD*Requesled Rough Final I unciffl a amkies of perjury. NAME / LioalseNo. I e° Signatuae LicenseNo �C D/l��O Tel No. 97 b� 6�Z `- 6 L 6 'L Alt TeL No. —'i7 �' 3'7 - :s 7 3 S INSURANCE WAIVER; lam aware that the Lioalse does nothai a the eg avalar t as required by Ma%xfl iseas Gaul Laws my signam cn this pemrit appbmbm wastes this mw*MTOI e check one) Owner Agent Telephone No. PERMIT FEE $ �aus�