HomeMy WebLinkAboutMiscellaneous - 256 Rea StreetA Date .e; - /.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... t-& ...........
has pLftission to perform ... /f- C ......... G`
.. e ....... . (; .............................
... . ....
f'cf. g�. -.1 .............................
wiring in the building of ......................
at ........... ...... :t� ................................. . North APoover, Mass,�
..
Fee.3.5) .......... Lic. No.. ...............................
09- 3—dcl 1-01
CAL INSPECCOR�
Check #
5312
THE COMMONWEALTHOFAWSACHUSETTS Office Use only
DEPARTNIFIVT0FPUXJCSAFL7Y Permit No.
BOARD OFFREPREVEVHONREGULWONS527CAR 12. 00
Occupancy & Fees Checked
APPLICATIONFOR PERNRT TO PERFORM ELECTRICAL WO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) I
! Date
Town of North Andover
i
The undersigned applies for a permit to perform the electrical work described
To the Inspector of Wires:
Location (Street &Number) Z56 /Ow
Owner or Tenant 17'e,04AI &)140,4m Ste a t
Owner's Address
Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead Underground No. of Meters
New Service Amps / Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nf4ure of Proposed Electrical Work s'ySiFinS
No. of Lighting Mlets
No. of Lighting FiXtures
No. of Receptacle Outlets
No. of Switch Outlets
No. of Ranges
No. of Disposals
No. of Dishwashers
No. of Dryers
l
No. of Water Heaters KW
No. Hydro Massage Tubs
OTHER-
of Hot Tubs
Swimming Pool
Above❑
Below
ground
ground
No. of Oil Burners
No. of Gas Burners
No. of Air Cond.
2—
Total
Tons Ll
No. of Heat Total
Pumps Tons
Space Area Heating
Heating Devices
No. of No. of
of Motors Total HP
No. of Transtormers Total
KVA
Generators KVA
No. of Emergency Lighting Battery Units
FIRE ALARMS No. of Zones
Totat No. of Detection and
KW Initiating Devices
KW Np, of Sounding Devices
Na'::of Self Contained
Detection/Sounding Devices
KW I Local� Municipal � .Other
Connections
fnstnarKeCoWf3ge. Pm arttotheleqttitMIUZOfNb%aclg>se(bclaaalLaWs
Ihavea=entl.IaAtyh►smm=PbhcyinckwalgComplete OpetaftonsCOverageoritssubstantialegnivalert YES NO
[have subn 2d validpwofofsametotbe0ffim YES Yyuubavetdt dodYES,pkasokdicatetbrtWofeoWtageby
Alled(ing Pale box L�
INSURANCE BOND OTEER (PleaseSpecify)
EsmrtaledValueofElectiicalWolk $
rVotktoStart IrLpectionD&Regtlesled Rough Final ?
>igledundAieR attiesofpeijuty.
1RMNAME !0 LicNo. /
jamsee�(/1!/ Signature �— licmscNo
7-� /� Busincss Tel.No. � 6rZ 6?-
rlrlixe �� c��i� ST �'/ `% �� Alt Tel No.
)WM R'SINSURANCEWAMFR,Iamawarethatthelicmsedoesnothavethemtiar=coverageoriissulsimbalegrrdle It as requiredbyMassachuscitsGme alLaws j
xl thatmysignatuteon thispennit application waives this mquiremerit
?lease check one) Owner ® Agent
Telephone No. PERMIT FEE $
Sign -5757777777 or Agent
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston; Mass. 02191
Workers' Compensation insurance Affidavit
Name Please Print
Name:
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.
h
Company name:
Address
City: Phone #:
Insurance. Co. Policy #
Company name:
Address
c
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 $1,500.00
and/or one years' imprisonment_as w.ell_as_civil,penal iesintheform of-a.STOP WORK ORDER..and..a.fine..of_(.$iD0.00)_astayagainst..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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature.
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 I]
Licensing Board
E:j
Selectman's Office
Contact person. Phone #:
Health Department
Other