HomeMy WebLinkAboutMiscellaneous - Suite 3010
Location 4 S 1 A NCDOV &Z- �7
No. Date t o
MOR71y TOWN OF NORTH ANDOVER
d , ' „ Certificate of Occupancy $
* _ ; • Building/Frame Permit Fee $
s.
A uFoundation Permit Fee $
scMs .�
Other Permit Fee" $
Sewer Connection Fee $ C
6
Water Connection Fee $
TOTAL $"'
(�r Building Inspector
8867 Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This fora 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.
****************Applicant fills out this section*****************
.06PLICANT: R, rc. (&Ji(v 77os r Phone �300 -C,s3- 1;
LOCATION: Assessor's Map Number Parcel
Subdivision
Lots)
✓Street L/ S ( 4 S7-e-�-r St. Number
Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
L141' -re Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
NORTHANDOVER
OFFICE PARK
September 27, 1995
Mr. Robert Nicetta
Building Department
Town of North Andover
North Andover, MA 01845
Dear Mr. Nicetta:
This is to advise you that Birch Realty Trust has our permission to perform
demolition/renovations of the space located on the 3rd floor of our building known as 451
Andover Street or North Andover Office Park.
Sign�.d
Patricia A. McMahan
Property Manager
451 Andover Street, Suite 210 North Andover, Massachusetts 01845-5070 Telephone 508/685-8535 Facsimile 508/687-6043
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'A .i 0260
Date .....1..`.'!........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................ k . (..4.... t ... IL.E-14 ........ ...........
has permission to perform ....... ............................
wiring in the building of .....
at ....... . ......... S )— Y,,rth Andover, Mass
Fee... ....................... . . ..... . ......... . .
ELE icAL INSPECTOR
Check #
Commonwealth of Massachusetts Official Use only
Department of Fire Services Permit No. ' L�
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 Electrio e (ME ), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I
City or Town of: NORTH ANDOVER To the Inspe tor- oy Wires:
By this application the undersignted ives notice o his or her, intention to perform the ele ical wescri ed belowi_
Location (Street &Number)
Owner or Tenant
Owner's Address
No.
Is this permit in conjunction with a building permit? Yes P� No ❑ (Check Appropriate Box)
Purpose of Building d F Utility Authorization No.
Existing Service Amps Volts
New Service Amps / Volts
Number of Feeders and Ampacity
. Location and Nature of Proposed Electrical Work:
E
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
0
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
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
rnd. rnd.
No.of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I 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
No. of Waste Disposers
Heat Pump
Number
T
W ��
No. of Self -Contained
Totals:
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 Kms,
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
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 desired, or as required by the Inspector of Wires.
Estimated Value of El ctrical Work: (When required by municipal policy.)
Work to Start: G ( t Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C V RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the
licensee provides proof of liability insurance ' cluding "completed operation" coverage or its substantial equivalent. The undersigned
certifies that such coverage is in force as exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I cert, under the pain and enalties of perjury, that the information on this application is true and complet t
FIRM NAME: � V (�={\ _ S -\(S ��" ��" LIC. NO.:
Licensee: -� h A, -N Signature ��,�C LIC. NO.:
(If applicable, eVikr "ex t" in the license pnumber line. p ®� Bus. Tel. No.1,.P11:�� � � !S I
Address: ® � l � 5'� O ��!'�(�` 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: 1 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
Owner/Agent
Signature Telephone No. PERMIT FEE.$
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
Name (Business/Organization/Individual):
Address: F10-
City/State/Zip:
011 Lffphone #:
UV
[-7-1 q `I �
Ar�yoemt ployer? Ch�appropriate box:
ployer 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. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 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
11.0 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.
I 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 information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: � (i(\c� (1
Policy # or Self -ins. Lic. k—K-,J C h0 Expiration Date:
�faow_��_2(�d—h
Job Site Address: �U � e> � � City/State/Zip: 0 0,(Q`
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 certif
Y under the ,pains and penalties tof perjury%that lite information prov ded above is true ancorrejct.
Signature: Y \C A /lid 1� k 1 V k 0.^ 1�� , 9a1 q 1 / 1
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 #: