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HomeMy WebLinkAboutMiscellaneous - 97 BEVERLY STREET 4/30/2018 (2)Date ..:4.� ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that J'� ," ke ....................................................v ........................... I'( \:� -� .............................................................. has permission to perform /�,l �� -F --v ........................................................................... wiring in the buildin of......,.. 6"t , t� ............................ ........ ............ at ............ 7 ......... 3ev P"e4p," ........................... . . Kprth A 9 dover, Mass. 60 Fee.�� . . ......... Lic. No�,)7_9_7�, ...... ..... .. ...... ... ...... ...... .. ........ INSPECTOR Check n Commonwealth of Massachusetts official vpsse only y Permit Na r , Department of Fire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS Rev- 1/07] (leave blank APPLICATION. FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be peifoivied in accordance with the Massachusetts Electrical Code (lVffiC), 527 CMR 12.00 . (PLEASE PRINT HEff OR TYPE ALL INFORMATIO Date: lD �-16 - City or Town of: `� _ �' To the Inspector of Wires: By this application the undersigned 'ves notice f his or her intention to perforin the electrical work described below. Location (Street & Number) — Owner or Tenant Telephone No. ?78' r -yk Owner's Address Is this permit in conjunction with.a building permit? Yes ❑ No ❑ BLDG PERMIT #' Purpose of Building Utility Authorization No. 17 Existing Service Amps Q/ olts Overhead 2 Undgrd ❑ No. of Meters a New Service Q� Amps I fJ 190Volts Overhead (2 Under d ❑ No. of Meters Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work: rmmnletinn ni'thv fnJlnwi»o t.,h]o ...m. ho wmiio 7 1 . r1 .7 s J777'' No. of Recessed Luminaires - - - - No. of Ceil.-Susp. (Paddle) Fans j --F.— No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool AboveEl- Elo. d. rnd. o mcyergenig Batte Units No. of Receptacle Outlets No. of Oil Burners FRE ALARMS No. of Zones No. of Switches 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 Heat Pum Totals "`— Number ___ _ Tons - KW No. of Self -Contained. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW I Local 0 Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systemcess: or No. of DeviEquivalent No. of Water KW Heaters No. of No. of Si s Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desiret4 or as required by the Inspector of Wires: Estimated Value of Elec 'cal ork: (When required by municipal policy.) Work to Start: lj pections to be requested in accordance with NEC Rule 10, and upon completion.. INSURANCE CO : UAless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.. CHECK ONE: INSURANCE El BOND ❑ OTHER. ❑ (Specify;) I certify, under the pains a d penalties ofper' that e iT!fifion on this pplication is true and complete: FIRM NAME: E7,/LIC. NO.: Licensee: Signature LIC. NO.: (If applicable nt " e t" in t e nw b 'n us. Tel No.: % 3 Address: — L %� fg Alt. Tel_ No.: }7�—� 9?-�� 7 *Per M.G.L. c. 47, s. 57-6 1, security work requires Department of Public Safety "S" Licen 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: $ i7 3. UNDER GROUND INSPECTION: Passed — [ j Failed — [ ] Re -inspection required ($50.00) -1 ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: MAiL+ t-ALLLnL, 114Al iVi\AL kylluu: NAlwMM Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) [ ] r Inspectors' comments: (Inspectors', Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED. IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50:00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accideiiis Office of Invesfigations 600 Washington ,Street Boston; AIA 02111 www mass gov/dig .Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant Information M M-ava D, -i,.+ t Nameusiness/Or aniaation/Individual {B g )A14_J .: Address: g CST s T City/State/Zip:. .Dl U Phone #: 9 7V .3 2 z/: Are you an employer?. Check the appropriate box: T -E of project (required): p ) { 9 } 1. ❑ I am a employer with 4: ` I am a general contractor and I ❑ g 6. ElNew construction loyees (full and/or part-time). have hired the sub -contractors 2. a sole proprietor or partner- listed on the attached sheet 7. E] Remodeling �` ship and have no employees Thome sub -contractors have $, ❑ Demolition working for me in any capacity. employees and have workers.' comp. insurance.t 9 Buil4in addition ❑ g [No workers' comp. insurance ired required.] 5. ❑ We are a corporation and its 10.❑ -Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their •. u.... 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof. repairs , ' insurance required_] t c. 152, § 1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] N *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 6r 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: 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). Tailure 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 �f 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 cer ' un de to pairs and eno erju tat the information provided above is true and correct.: Signature: Date: 0 . ` O / Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 3 Informatim and Ins ructions Massachusetts General Laws chapter. 152 requires all employers to-Trovide workers' compensation for their a nploy.,ees. CtJ 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 bean employer." MGL chapter 152, §25C(6) also states that. "every state or local licensing agency shallwithhold the issuance or renewal of a license, or, permit to operate a business or to construct buildings. in the commonwealth for'any applicant who rhas •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 havebeen presented to the contracting authority." Applicants ' Please fill out the workers' compensation affidavit completely, by checking the boxes that applyto your situation and; if necessary, supply sut= ontractor(s) name(s), address es and phone number(s) alongwith their certificates `of insurance. Limited Liability Companies ¢LC) 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 r Industrial Accidents. Should you.have any questions regarding the law or if you are required to obtaina workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insuiance license number on the appropriate line. City or 'Town Umcials 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 pemait/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 maybe 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 hoI.me o1.wner or citizen is obtaining a license or permit not related to any business or% commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. r The Office of Investigations would like to thank you in advance for your cooperation n 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 Aeci&6 . Office of InvestigatiQ.n's 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or. 1-877-MA,SSAFE Revised 4-24-07 Fax ## 6..17-727-77.49 www.mass.gov/din If Date. --.. :7 �:..' (^... 0 q TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .....� .:! .<�{'� . ���,� . �, . !/ .......... . has permission for gas installation,.. %:..•.�./._r_.� "Al �;.�►�-....:..�% in the buildings of at .............. .. -'� . , North Andover, Mass. el Fee: f>. r. Lic. No..,,?)��/.61.. \ . �� I � cs...... . G, GAS INSPECTOR Check # c2o L 51.76 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO ©O GASFITTING (Print or Typ ) Mass. Date 3 L32/70 Per/Lmht/ # Building Location 12 a L_L._ Owner's Name Type of Occupancy_ P( (� New 0 Renovation 0 Replacement Plans Submitted: Yesp ' No 0 f Instating s Address Name_. CA LL 4- Business Telephone �) l (I� Name of Licensed Plumber or Gas Fitter Check one: B—Corporation 0 Partnership 0 Flrin/Co. Cert![icate # INSURANCE COVERAGE: I have a current 1► bi1Hy Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No :p If you have checked yes. please eiindicate the type coverage by checking the appropriate box. A liability Insurance policy p' Other type of indemnity O Bond 0 OWNER'S INSURANCE WAIVER:.. 1 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 OwnerO 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 knorvlectge and that ail plumbing work and installations performed under the permit Issued for this application will be in compliance with alt pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene al laws. Type of Ucense: Title Plumber Srg u e o c nse um: er or Gas viler r — nsfi(tor � , /�� City/Town aster Ucense Number L Af,f1y),V-n—T—rTCfTK �OTKTF — Journeyman �✓ 1 i • 111■111111 ���•■ 1111 ���I 4TH FLOOR_ -j Name_. CA LL 4- Business Telephone �) l (I� Name of Licensed Plumber or Gas Fitter Check one: B—Corporation 0 Partnership 0 Flrin/Co. Cert![icate # INSURANCE COVERAGE: I have a current 1► bi1Hy Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No :p If you have checked yes. please eiindicate the type coverage by checking the appropriate box. A liability Insurance policy p' Other type of indemnity O Bond 0 OWNER'S INSURANCE WAIVER:.. 1 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 OwnerO 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 knorvlectge and that ail plumbing work and installations performed under the permit Issued for this application will be in compliance with alt pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene al laws. Type of Ucense: Title Plumber Srg u e o c nse um: er or Gas viler r — nsfi(tor � , /�� City/Town aster Ucense Number L Af,f1y),V-n—T—rTCfTK �OTKTF — Journeyman �✓ 1 Location' No, f/r � Date TOWN OF NORTH ANDOVER or, • pL A Certificate of Occupancy $ _ CMUS Building/Frame Permit Fee $ _f Foundation Permit Fee $ Other Permit Fee TOTAL Check # Building In E&tor y TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: // Q SIGNATURE: Al 11&~-O� Building Commissio2EEm Twtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 7 uI O Map Number Parcel Number 111.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply AG.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 44 �r 7 Pve� /y s7~ Name (Print) Address for Service: LZP r Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Sir ature Telephone SECTION 3 - CONSTRUCTION SERVICES Licensed Construction Supervisor: /� t'Ll censed G�oristruction Supervisor: Not Applicable ❑ 7 License Number p � 74Y"A &f g, X) Q ad% rd%� ,1 /�( / y ��/ Address t 82 Signature J Telephone �0© Expiration Date Home Improvement Contractor 3.2 R2;�kA .� Not Applicable ❑ S) { Company Name Registration Number C1 Address Expiration Date Signature e-"' 1 Telephone OU rn X Z O - 11 (V I�K SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) 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 permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: �ernoY-2 Fl,5�,-V4� {'os24 dPd �uJd ler) 4c !�a!'1`Q ', ZE, I � ©� S , D� �O"f, he u/ hU of -,A5 S nA2l-�,,Q 0/�� ov<c1 �\ oR uS+' � 'q C2 o R -t o5 -1'S ix �� , o11oF O �a11 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant 1. Building ©� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf in all matters relative to work authorized by this building permit application. <--Q 111 < nom Si nature Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 4--V—,-as I, Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Le -C),, Le Print Name n j ^ t�70 �X-- Si tore of wner/A ent Date I NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2 ND 3 RD SPAN DINIENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE *t. FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT ��-t°V/� f� �"�`� PHONE 3 S!2, 36 V- g ASSESSORS MAP NUMBER V" LOT NUMBER SUBDIVISION LOT NUMBER / STREET &A STREET NUMBER q7 OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS ; (tom 1 :T (t,S le DATE APPROVED 1A1*1,t")b'... CONSERVATION ADMINISTRATOR COMMENTS DATE REJECTED DATE APPROVED TOWN PLANNER DATE REJECTED CON 4ENTS DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR AS GQ - A N � O *4 A *4 O(46 �0 e �a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: 5p��� r Location: q" 7 L�*J V r City M o, A \D6 trek Phone 655 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity = I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance Co. Policv # Company name: Address City: Phone#: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and'penalties of perjury that the information provided above is true and correct / Signature / �G �� Date .' O C� Print name 5-f"�—`�`— Phone # �� 3 3 Official use only do not write in this area to be completed by city or town official' ❑ Building Dept El Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andover Q� tAQ RTH .,6l6 Q Building Department o 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 09Abo SSACHUS���� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a. The debris will be disposed of in /at: Facility location Z Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. STEPHEN M LEE 6 HAYMAN CIR NEWTON, NH 03858 f �I tmon,raeald .,/ dlwadu em RD OF BUILDING REGULATIONS ,ONSTRUCTION SUPERVISOR CS 061358 06/28/1964 06/28/2001 Tr. no: 10852 rstricted To: 1G Administrator m M C .1J m 0 m m y CD O ICS Z y �e CAD so O CL CL y O A CD CDCL O rF c� d CD CCD O CSD C CD yCDe �O y CO CD !l W. 'Ed rri n O z cn �I ���o 0_ O �•K O cr N a 0 S. ®10 N) §4 = � ® 0 ® S7 'fl C2 a o mZ No�c • =r -a N O N 'T1 a a a = Pm CD -4o m d ® CO) N � : Om m _ =o:# c®s m O 70CM ..� O 0 �• C2 � O N C! m A a y c o = 50 fl• m o sem: m C<D CA C m 0 CD c o -% pay a 1i� O ca = O N y = �: a�� c C ,^ 'SD FL V — N �O ) N N R2 -, 4- mp may: =: CD . Fm m�.r � p !9 rt o� C m � ^ c m � 6N vJ y 'c 0 sW O O : � I _ a v, r CD = �1 (n cn W w 0 7d O CA w O 0 x Irl G7 C b Or CJ 7d 0 0 )Nq 0 c // Z 0 Ld Ul Z'z �The Commonwealth of ` _�'� Massachusetts �! Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only / Permit No. / /6a Occupancy & Fee Checked 3/90 (leave blank) 1 APPLICATION FOR PERMIT TO P All work to be performed in accordance with the Maa PERFORM R Mcal Code, 527 CMR 12:00 E L ECTR I CA L W R K (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date City or Town of ../L�0 The undersigned applies for a permit to perfori Location (Street & Number) Owner or Tenant — JlAn 3. Act,,, the electrical work described below. To the Inspector of Wires: Owner's Address_ &,4,V1,7-. Is this permit in conjunction with a building permit yes ❑ no (Ch,,;k Appropriate Box) Purpose of Building Utility Authorization No. Existing Service bU mps /aU / )�/0 Volts Overhead Er Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nat -re of Proposed Electrical Work- or No. No. of lighting Outlets No. of Lighting Fixtures No. of Hot Tubs Above In No. of Transformers TOTAL KVA SwimmingPool rnd. ❑ rnd ❑ Generators No. of Receptacle Outlets No. of Oil Burners KVA No. of Emergency Lighting No. of Switch Outlets Batte Units No. of Gas Burners No. of Ran es No. of Air Conditioners TOTAL FIRE ALARMS No. of Zones No. of Detection and No. of Disposals HEAT TOTAL No. of Pumps TONS TOTAL Initiating Devices No. of Sounding Devices No. of Dishwashers TONS KW No. of Self Contained S ace/Area Heatin KW Detection/Sounding Devices No. of Dryers No. Heatin Devices No. KW Municipal -- Local ❑ Connection ❑Other of Water Heaters KW of No. of Si ns Ballasts Low Voltage No. of Hydro Massae Tubs Wirin No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy ncluding Completed Operations Coverage or its substantial equivalent. YES VNO ❑ 1 heave submitted valid proof of same to this office. YES 7NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 21 BOND ❑ OTHER ❑ (Please Specify) — CC OliNrt / S Estimated Value of Electrical Work $ �, % (Expiration Date) Work to Start 1/55- Inspection Date Requested: h Signed under the penalties of perjury: Rough Fina, -16, 1 (0I7t c FIRM NAMEJZ -� -- _ U. Licensee J &me/ ii, LIC. NO. Signature _ Address e,-S� SIG LIC. NO.� Bus. tel No. —l%�— OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this application waives this requirement. Owner Agent Tel (Please pp q 9 (Please check ongr (Signature of Owner or Agent) Telephone No. PERMIT FEE W Date..... / 0 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............. ............... j..... i ....................................... has permission to perform ........................ ....... j ................. ................. wiring in the building of .........;.,j..' ........ ! ....... ............. p ............ 1........... ......................... at ..... z .......... r ...—.—l1111I North Andover, Mas. Fee.2,P.d).... Lic. No.. - .../..;t .................................................... ELECTRICAL INSPECTOR 02/20/95 09:23 WHITE: Applicant CANARY. mg PINK: Treasurer GOLD: File