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Miscellaneous - 971 SALEM STREET 4/30/2018
FPP- Location 571 5 /d 70 57 f No. CDate H0 TM TOWN OF NORTH ANDOVER Certificate of Occupancy $ �o Building/Frame Permit Fee $ s+cMus `� Foundation Permit Fee $ s Other Permit Fee $' Sewer Connection Fee $ Water Connection Fee $ Baa c TOTAL-^ ex 179 b ding Inspector o } 10955 Div. 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CIO �, y 'D O J� Y �Cos rt: � m m o+ C. c o c O �. ft . o m N r v '° c 9�;e cp r v �4 Ol 0 9 . old 0 c all '° c cp rzo ro W �4 Ol 0 9 . old 0 c all 3 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction , have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicants fills out this section***************** APPLICANT:, ,,, l b,.. Phone (_,,?5- (a - c�S�S LOCATION: Assessor's Map Number Parcel Subdivision Lot (s) Street �A 1 �_7_ k-1 IS 4-1- le- � St. Number _g Z l ************************Official Use only************************ RECO IONS IONS OF TOWN AGENTS: Date Approved 5_� ' / Conservat: on Administra or Date Rejected Comments 0 1�1Wgn dS U ! //l w) t i Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date.Rejected Received by Building Inspector Date rx. S I --T \li • 0 Ln v; co �-- n/f CaMcrinc- M. 51nehr 33�— I' /33,0 n/F Toth ii�Kozdro5 _r-rm = (D C Ga C'7 n '- O£ o 0 0 G �n G H m O O O G' m r -n o a Y• a nnam H• �O "3O rt: m O rt =rO U) o m m N a n 0 7 N cn O G a? 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(D �O n7 Ar -3 0 n xro� t7 p 0 H(D rt c (D rt W W U)3y U) z Ar rt" ri O to Fh Ar Y Pr N N 3 G 0 rt Y- 0 0 G 0 O rt G Pr rt to n 3 3 O Y• , Y 't7 w O ` d 4C) M 0 Y• O rt 0 N r� O co r7,to to H m Di G Y rt Y :3 toHO (D ._{ rn0 0 Nt.O G to o0cO n c (D m rn 0) rr £ c O H m a n wU) tr H cr) LO m W Jim NG H C ID n 'D H m G N C n G O n < ft (D a (D m 0 > rr G m CrJ < cn O o G 'a m ' G (D U)N Z rz ro G a 0 r 0 O 0 a> o m rt rr O rt n 0 cO w a £ rt r 0 O to �26Ar O O O 3 C 0 K 0' to n Pr m G r— H a- (D (D a K n to 0 N m H N rr (D K:7 0 0 rr G G to 0 (D r+, 7 H to (D (D G m N a 0 Y m `k nm rtc,,w rtH P� Y m 3 a H• S ro Ln m cn m rr rr �-3 a rr 's (D 0 U) ri Y• £ Y- � H 6 G G O rr W K � ] G C) Ar 0 rt n y (� rt, H 7- W m ` Op z r -i K ((D rt U) n 0 m Y m 0,n ,n >✓ n W 0 0 0 rt G Y G 0 O( rt, p rr OD (D O rt 3 n m w £ a m 3 JY 0 G m rt C rr a 0 rr ] (D to a K rr (D 3 O O rt Ar £ rh ::)7 U) N ? rt m - w m rr c- n • ? m t-0 G (D n 0 C) Cl :3- 0 rr m o N O G G G c O r•t O ri (D (n G Y a (D ri rt Y• N N iv ri G O Sv H G cO 7 to m n rr C rr H w to 0 Ar (D Ar H ? £ £a£ 0� N to G 0 0 0 c n t -h ro orotv�c> sv�oma W rr Pr O .O a G m c 1r Y• ri 0, cn m z lS rt N 0 K A n N Ln ro 0 N G Pr (D U) a LO m a� m 0, Ln �o CA w co 0) O rr (n G K U) 0 m m rtm G K rr rod ror�z 1-� F- U) 0 A� rt w to H c m c m r r a x � z • • t3- 0 Kz� C .. 0 c !-�tort- 0 Ln K N r- 0 to K colo m � � G rt K 1y m to Y1h Design Works (R), Somerville Lumber, # 238, Phone # 741-3200 Tue Apr 2946:38:211997 Post Layout for Deck 1 Un 16' 2"16' I------------------------------------------------------------ See------------------------------ -- See the Specification Sheet for More Details 2" sTT949a Ga0K 0; 408gg u0T4v*T;TD8d9 aq4 aag InoSnrl 313aQ L66I IZ:8£:916Z ad'V an L OOZE-IVL # auogd `8£Z # `jaquin-I ajjjAJalU0S 6(g) sjJoAj u-NisaQ Date .x*z.-/7 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING AMU r This certifies that .... ................ /!.... . has permission to perform ....... � ......... plumbing in the buildings of ... ......................... at North,Andover, Mass. Fee: L i c. No.. Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING nLl (Print or Type)' I& i or \ 20©� J"'�-� %�vtCOv ex�` ,Mass.. Date �e.0 M, r Permit # wv Building Location -SI k �kQlyn S�T Owner's Name ArOICN Uo'r AmC-�oJ 2y- M a \$LkS"`� Type of Occupancy_ S k New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No FIXTURES Installing Company Name R&.1 c��0 _ C� T £ kA Check one: Certificate Address O Corporation i No��v1 d(3J�� i MA ❑ Partnership t Business Telephone (0 [f Firm/Co. Name of Licensed Plumber T\omo,.S c ) i -\n01<— INSURANCE COVERAGE:. I have a currej liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked .yg s :" ease indicate the type coverage by checi.Ing the appropriate box. A liability insurance policy 5 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: Owner ❑ 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Q) Title Signature of Ucensed Plumber �,/ / Type of License: Master J Journeyman ❑ City/Town ke� APPROVED (OFFICE A M�SUS ONLY) �Ucense Number � C) ` � 0 �iiiiiiiuiiniiiinioiiiiii ��o�n�nnm�n�nmu� ���uoonunno nmM �mmOMmmEMn SEEMS son EnmEnmm Monnom EMMONS'numm�mmNu inn■ mom mom �mnnnm�mnnnnn Installing Company Name R&.1 c��0 _ C� T £ kA Check one: Certificate Address O Corporation i No��v1 d(3J�� i MA ❑ Partnership t Business Telephone (0 [f Firm/Co. Name of Licensed Plumber T\omo,.S c ) i -\n01<— INSURANCE COVERAGE:. I have a currej liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked .yg s :" ease indicate the type coverage by checi.Ing the appropriate box. A liability insurance policy 5 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: Owner ❑ 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Q) Title Signature of Ucensed Plumber �,/ / Type of License: Master J Journeyman ❑ City/Town ke� APPROVED (OFFICE A M�SUS ONLY) �Ucense Number � C) ` � 0 Date .. f a " 17 7. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... .. e�.:...� ....?� .1. .. . has permission for gas installation ...... in the buildings of .............................. at .��%....--�:. --' ...,:. , North Andover, Mass. Fee d? ..... Lic. No. �' '27 ........... GAS ISPECvD Check 4249 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) y� 2 0 © 2 r o`t: I� 9 Qa�-�-�-, {�n�oUe.� ,Mass. Date �eC-a Permit Building Location Slk ScAi_.nr, 'S- CCQZ Owner's Name NRR ACe\ 6O J � Q)� � Type of Occup ry New n Renovation ❑ Replacement d (, Plans Submitted: YesQ No 53/ Installing Company Name N`iC, �C-C�`�-`C ��� Check one: Certificate AAA. ❑ Corporation W Os' A-V\ Avec OJ Qr AkA d V Q, ❑ . Partnership Business Telephone okl-(?) —'(9 �) l •- —+-4—" [ Firm/Co. Name of licensed Plumber or Gas Fitter T\nOYV� 0,S 0 _ INSURANCE COVERAGE: I have a curren (ability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No O If you have checked Les. please Indicate the type coverage by checking the appropriate box A liability insurance policy ISS 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: OwnerEl Agent O Signature of Owner or Owner's 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. gy. T of License: l��L d` Plumber Signature oLicensed Plumber or Gas Mer Title slitter ster License Number i1•A-,, k0 pty/T Joumeyman ( I L �■���vv■1111■MEN4THIFLOOR Q����l�J��O���mom NoNEONMIA 0 Installing Company Name N`iC, �C-C�`�-`C ��� Check one: Certificate AAA. ❑ Corporation W Os' A-V\ Avec OJ Qr AkA d V Q, ❑ . Partnership Business Telephone okl-(?) —'(9 �) l •- —+-4—" [ Firm/Co. Name of licensed Plumber or Gas Fitter T\nOYV� 0,S 0 _ INSURANCE COVERAGE: I have a curren (ability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No O If you have checked Les. please Indicate the type coverage by checking the appropriate box A liability insurance policy ISS 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: OwnerEl Agent O Signature of Owner or Owner's 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. gy. T of License: l��L d` Plumber Signature oLicensed Plumber or Gas Mer Title slitter ster License Number i1•A-,, k0 pty/T Joumeyman ( I L 'a Location,/ ` No. %' Date NORTH �TOWN OF NORTH ANDOVER Of+"•O '•,O O? • • OR 1- n " Certificate of Occupancy $ s'•••°�cNuBuilding/Frame Permit Fee $ sst Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ASS Check # 173$9 -� 6/ Building InspeO&I, t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 3 BUILDING PERMIT NUMBER:-'Zj DATE ISSUED: SIGNATURE:J/-2 ( Building Comm1 sioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning Disttid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'redProvided R red Provided 1.7 Water Supply M.GL.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT I n 1 a w 1 1 u U 1 J tl I C:1. T C J 114 U 2.1 Owner of Record Name ( rint /--)Address for Service: A Telephone 2.2 Owner of Record: Name Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: ISA %PAI 1. \ Licensed Construction Supervisor: S-�. V00\A -1532-qhl�S 3.2 Registered Home Improvement Contractor Company Name .22 � ? D vl Not Applicable ❑ UCOso 2° License Number G t 177^v4 Expiration Date Not Applicable ❑ 16X71'9 Registration Number L Expiration Date MU rn X z rn L0% c 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 it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: CW'5 N_ N)C-N ft-v.Z FA 0-k,,AAS SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICLAL USE ONLY 1. Building s Doo r (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 '$ 1000 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH DING PERMIT I, r v/_J0, � Z as Owner/Authorized Agent of subject property Hereby authorize to act on My beh , m a ers ativ work authorized by this building permit application. /�/ Si e of Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 51" ,as O er/Authorized Age 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 P"e' Si a e of Owner A vent low. NO. OF STORIES Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST777RD 2 3 SPAN DIMENSIONS OF SILLS DIlVIENSIONS OF POSTS DEVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE s FORM U e LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT ¢ �-�-,:6,, PHONE LOCATION: Assessor's Map Number. SUBDIVISION G STREET l �derc PARCEL LOT (S) ST. NUMBER *****************************************OFFICIAL USE ONLY**'k**********************'r********* CONSERVATION ADMINISTRAIR DATE APPROVED �S DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD EALTH TH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS z5--, S"t-u 2 -r -'— PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE, Revised 9197 jm . % ' �i `, '• L it t- 3 3 N (D O 4 10 o O 1} ~ Z a e 1 - • II �nl (i' (D rt C1, W w 171 O H p z fD ••� pOm m � n (D n C H K C) P. ? z 0 (D Y• N Y- G K Ln In 10 N (D 1 "— I 331 n/f CaMerine M, Voehr J al 133.0' (p/an) 691± W 1{ u�•ti...rkN.wa. 1 MW Pq N (D TgN 4 10 o O 1} ~ Z a e 1 - • � W 1{ u�•ti...rkN.wa. 1 MW Pq :u •�_ 133,0-- N (D 1 •1 O K K N 0 rr M M C G W H S o • � (i' (D rt C1, W rt H o, 0 0 0 (rm` vl (DM , O N 7• x 7. 1'• 7? Ul (D m K K O. (D Y 1.0 M a 0 rr W Y• (D 3 m P. ? O (D (D Y• N Y- G K (D S 0 .rt ? 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G m C (D N G' (D 0 N O G G m n W " a -'; (D n 7 0 K 0 G 0 K 0 K N 0 0 7 /o (D a ►< Dy rt G (D , (D N 7 Y• (], (D • n ro G a, 0 O c (D Nti' n rt Y• N N n rt 010 w> O O' ¢1K�00 7 N N £ rr M ..K W W N c La WOrt 0 0 a <NNO... 0 rt 7• F� ►•c LT N K W (D 7 r rr H W m 0 f✓ tT (D (D 1s, K n N 7 : 0) (D W H 7 £ ,N (D N UI rr (D ` '< 7. 0 N CL N £ Y. ����, :)1. 0 rra. 0 3 7 0 UciNmZ) ?I >y 5H O0 7 (D N Oj O .Y; rI M ro prom�o> I-• W r O m m W rt W O ka 0, 7 (D 7 7C Y• K (1, •• N (D z •• t7 rt N O K K N rano 0%.o rr W M -I w 10 ro p l0N:7W (D U) .D. kA (D W Ul (D 0, ►- • .. (n (D w W 0 rr N G K (n Z) (D (D rt (D G K rt ro° HEn 0 W rr W N K 7 (D 7 (D rr Q, x •• 0 z >y C4 .. o ::J •• G K oj ►– >y w rr O In N K 7 < I -• N W N 0 N K coko0 m rnP.N ,A W G rt K >y (D N Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 102798 Expiration: 7/2/2004 Type: Private Corporation D & H CONSTRUCTION CO. INC. Michael Shapiro 33 Central St. _ Peabody, MA 01960"'``_ A dminktrator r<cs[ncted: 00 MICHAEL M SHAPIRO 33 CENTRAL ST PEABODY, MA 01960 Administrator ��ze l�°m�ia��ituse2�.fit i `�'�adczclu BOARD OF BUILDING REGU 3 :icense: CONSTRUCTION r�t SUPERVISOR r Number. CS 068059 3irthdate: 06/17/1963 " Expires: 06/17/2004 Tr. no: 25722 r<cs[ncted: 00 MICHAEL M SHAPIRO 33 CENTRAL ST PEABODY, MA 01960 Administrator CONSTRUCTION CO., INC. 33 CENTRAL STREET PEABODY, MA 01960 1-800-564-5822 - (978)532-8188 FAX (978) 532-7477 Customer /t Address Job Address city A- Telephone _M-) Specifications Ll" /t/ .7 I i Cash price of goods and services: ............................................................................................. .................... $ —,A Down payment or payment at commencement: ...................:..........................:............................................. Payment when 50% complete: Balance upon completion: :............................................................................................................................. $ P P --r Contractor will do all of said work in a good workmanlike manner. Contractor warrants that the workmanship and materials used for the completion of this contract to be free from defects and leaks for a period of three years from date of completion. The owner agrees to notify the contractor in writing, signed by the owner, of any defect in workmanship or material. The contractor shall be liable only if it fails to repair any specified defect, including defective repairs, within thirty days of receipt of notice, but not otherwise and in no event shall the contractor be liable beyond the cost to it of labor and material required for any repair work. The contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. This warranty is void if payments have not been made to Company Agent or Foreman when due and in the full amount specified. You may cancel this agreement if it has been consummated by a party thereto at a place other than at address of the seller which may be his main office or branch thereof, by a written notice directed to the seller at his main or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. No work to be done on this property other than that specified in this contract without additional charges. This contract contains the whole agreement with -as. Company will furnish guarantee adjusted to the type -of work done on above property upon completion of this contract. Owner agrees that in event of his breach of this contract before work is started, Contractor may demand twenty-five (25%) percent of the contract price as its stipulated damages for the breach. This contract is subject to strikes, accidents, or other delays beyond our control. 1/we the owner(s) of the premises mentioned above, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according,:to the specifications, terms and conditions, on premises above described, which we warrant and represent that we have good local record title to as owners in our own name. _ In witness whereof, the parties have hereunto signed their names this F,'.:;- ,: ' day of 20 D ...Signed / 'Signed Owner Per V1, A Signed Owner Representative k 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/7,' " (- 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) "� Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector O 0 a w x x a is � � � .� �nb � U w f1+ 'nb o°G w "'a W 'nb ao' •� ii 'moo ao' ,-. cd w � � rA z .. i o cn G') O .CL R A •rte--„' i w?o� 1 Y C=* 20 m o CnCL Ec C/). Z Za�E �O y A h m N N L._ a Cn CCU z 10 A.w O E0 mo 4 acs m y m i c Ic Cf) C/)oQ E w C -1 H _O Z c O` o c a cm c 'c = m :moo a ~ 0 goes Z H .to 'at c° C Z 03.080 LU Ca o 4 c g CL x co ���� o 0 I CD C C W 'E m m CL ~ •� 3 "O di O � i e_c�. v o c' Krma c Cal c !C .G3 .5 'O CD c Z c 0 CL C.3 h c c c c C40 0 w cl N w N 19 w 19 W U) A Date ... 4:719 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... C, -- has permission to perform ........ .............. wiring the building of ................................................... 7 ........... ... ........ at .................. .... ................ , North Andover, Mass. Fee ..4��-ep—.. Lic. NOY99 ................ .... .. . .....�-�% ........... I .. -7�7 L 0-c � IR. I C -A -L INSPECTOR Check # —1— Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. a Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC),27 CMR 12.00 (PLEASE PRIN OR TYPE ALL INFORMATION) Date: 5 Q City o Tow of:I V K l AO dbV To the Inspector of Wires: By this application t e undersigned,�ives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant t �( al a_ -� Prb l'1 r, r4i Telephone No! Owner's Address ,yam Is this permit in conjunction with a building permit? Yes ❑ No x BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install low voltage security system at above location Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Trsformers KVA Trans No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd [Irnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners Detection and No. In nitiatin Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices No. of Waste Disposers p Heat Pum Totalp Number]Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW l Local r7MunicipaOther No. of Dr y Heating Appliances KW kru'riDryers NoSystems:* 1 No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts in ; No. o eve uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: / 0. Q (When required by municipal policy.) Work to Start: 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 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 ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Brinks Home Security LIC. NO.: Licensee: John Holmes Signature ,A LIC. NO.: 749C (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-657-0443 Address: 155 West Street, Suite 6 Wilmington MA 01887 Alt. Tel. No.: *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" License LIC. NO.: SSCO 001163 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:PERMIT FEE $ �j�Q� Signature Telephone No.