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HomeMy WebLinkAboutMiscellaneous - 85 MAIN STREET 4/30/2018W X Location- --�--` r a No. ='?� Date TOWN .OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # .33 —� 21963 � -� ```Building I s, actor t 0 0 0 10 0 ° i m A m m 7 S. O m N �. N A N � m W OD CA 0 CD r« D � r � aQ ° y c N w 00 i c H a � 0 4 �n O O � z z "o0n z O � 70 z v z 10 O A X 0 11 7Ry i m A m m y O m N �. N A N � 4 �n O O � z z "o0n z O � 70 z v z 10 O A X 0 11 tv a 1� Lv CCD tri o ° CDf L M, x�I J-1 CD �..o�o� CD m Sao dw �� e• E3P. `D CD * n �. Co =. a y CD CD -, CD A= I ° ��c�p�= Oct '7:1 Gd n C � o � o CL CA oo mm a 'n N [D o. CCD w a: o CD CD wcr o 0 a CD cr CD ItCD CDw cr �. CD �* —� CDCD CD � tv a 1� Lv CCD tri o ° CDf L M, on J-1 0' CD z CD ate. `D CD * n C 0 Ct O CSD Ln O = CD A= I ° ��c�p�= Oct '7:1 Gd O CL �•� .-r cD i w O `� CL CA oo mm m a 0 �cn5WCD� 'n N c �� o. CCD o CD a o 0 CD CD cr CD ItCD CDw cr �. 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Fee..................... Lic. No4.11p� .. .. ...................... .. ................... Check # 7275 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: a — 2 y 0-7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) gS C -L i in S Owner or Tenant 7" 0 h1 U e h -�u r Q Telephone No, ,igq -2,(- 3 Owner's Address 2 'Z -> 1?0 s, rh e�d0 LI - S' br, ti ah /os r'1// hqrP A :R 4 1/. 9 $�5-oV Is this permit in conjunction with a building permit? Purpose of Building Existing Service akO 0 Amps New Service Cy G Amps Yes LL!J No LJ (Check Appropriate Box) Utility Authorization No. 02 D Volts Overhead LJ' Undgrd ❑ Wo. 1f lAter ) Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: nd or, C Overhead K' Undgrd ❑ ra No. of Meters �15_ 1 cJ Irl t Completionfof the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires (1 Swimming Pool Above ❑In- ❑ rnd. gr d. o. o Emergency Lighting Battery Units No. of Receptacle Outlets d No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 46 No. of Gas Burners � No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers HeatPump Number. Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts to Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Tele ommunications Wiring: N.t,. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: /$r P> (When required by municipal policy.) ` Work to Start:_ • Z 9'--r_'7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. - INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless � N N Y the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [A,"—BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, Neat the information on this application is true and complete. FIRM NAME: G- L..e �, c> LIC. NO.:4 7 Licensee: --s -e (r- L e t, -i S Signature LIC. NO.: (If applicable, enter "e. Inept" in the license number line.) Bus. Tel. No.: A1k1�4-i� Zd � 3 Address: !(, a levsy R, f t �_ �! (ri U-6 %1 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ aa• ( 1-7-0-7 Pyk9 7 -� 7 Alt - r 3 1� y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): i7 6- Louis � / P c-� e c io r w Address: C/ plec/5o 4 �_ !�/ City/State/Zip: dA U Phone #: y 7t G( 7 JL 7 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 �. ❑ I 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.w rkers' comp. insurance. [No workers' comp. insurance 5. P>WWe 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 R. ❑ Demolition ). ❑ Building addition 10.0 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 infonnation. 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 their workers' comp. policy infonnation. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 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 certify under the pains and pe�rlties of that the information provided above is true and correct. 3- a ? C Phone #: v Gf %9- 4,d— % d 2 C 3 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 #: