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HomeMy WebLinkAboutMiscellaneous - Exception (107)"I/ _s O Date .-/ /0-1-ela... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that,.,.:...........G.................................................. v , has permission to perform wiring in the building of ..,.. `..:...?-?............... at AA01t ..��J� c� ............................. ,North Andover, Mass. Fee ...t ............. Lic. Nor, ELECTRICALINSPECTOR� Check # \(// 6G5>4 TRE COMMOATH ALTHOFMASSACHUSETTS DEPAITW7'0FPUBLICS4FETY BOAROOFFIREPREVE MONRF.GUTA770NS527CMR I2.-1 Y�V Office Use only Permit No. 611( � Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK 17" 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 To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address itl Is this permit in conjunction with a building permit: Yes t;1 No (Check Appropriate Box) Purpose of Building Poo 1 J V Utility Authorization No. Existing Service Amps / Volts OverheadUnderground r-1No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work t l S7 777 D , No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total TH; mance^overage PuMlatttothe taquitementsofMassachusctsGerfalLaws ave aam it Liability h>StuancePblicyinchxingComplelp Cove ageoritssubstantialequivalent avesubnmWdvalidproo fsmrtotbeOfiiw YFS �g the x SURANCE BOND OITUR F1 (Please Spetafy) YES El NO EsU►mted Vahrofflearical Wdk $ xktostart kgectionDateRecps(ed Rough Final _ nedurderTrFt Aesof I r+ -i_ l :MNAME LioffmNo. msee S7oyt' tJU�,o Sigretur: _ Licer&No n Busir�sTelNo. 92 6 kJ-H3 l�Wti G /V6, AIt TeLNo. ggR'SINSURANCEWAIVER;lam a that d -e I icmg-- does nothave the iranncecoveragcorits substantial equivalent as required byNiassafts2nGerier Lam that my signature on this peanit application waives this ragmeinent :ase check one) Owner® Agent Telephone No. PERiVITT FEE $ "7V Signature or Owner or Agent 1%. VA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Burners No_ of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones No. of Uri osals No. of Heat Tons Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW Nq. of Sounding Devices N,;:,oESelf Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal Other Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP TH; mance^overage PuMlatttothe taquitementsofMassachusctsGerfalLaws ave aam it Liability h>StuancePblicyinchxingComplelp Cove ageoritssubstantialequivalent avesubnmWdvalidproo fsmrtotbeOfiiw YFS �g the x SURANCE BOND OITUR F1 (Please Spetafy) YES El NO EsU►mted Vahrofflearical Wdk $ xktostart kgectionDateRecps(ed Rough Final _ nedurderTrFt Aesof I r+ -i_ l :MNAME LioffmNo. msee S7oyt' tJU�,o Sigretur: _ Licer&No n Busir�sTelNo. 92 6 kJ-H3 l�Wti G /V6, AIt TeLNo. ggR'SINSURANCEWAIVER;lam a that d -e I icmg-- does nothave the iranncecoveragcorits substantial equivalent as required byNiassafts2nGerier Lam that my signature on this peanit application waives this ragmeinent :ase check one) Owner® Agent Telephone No. PERiVITT FEE $ "7V Signature or Owner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigation Boston, Mass. 02119 Workers' Compensation insurance Affidavit Name Please Print Name:,.,'I Location: City Phone # 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. Policy # Company name: Address City: Phone #: Insurance Co. Policv # 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 wetLas_civil..penaltiesinlheformnfa..STOP WORK_ORDER.and_a.fine.of_(.$1,00..OD)_a dayagainst..me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone * Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Q Licensing Board Selectman's Office Contact person: Phone #: Health Department Other N