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Home My WebLink AboutMiscellaneous - Suite 2099919 Date. .7 . ........ ... . ...... .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Z ............. This certifies that ........ "7 ........ ...... ..... has permission to perform ...... .................. ...... wiring in the building of .......... ,r- • ...... ............ ,North And vex, Masy/ at ...... It ;ee Lic. N-'f//3a� ........ ECTRICAL R INSPECI Check # /L� Y Commonwealth ®f Massachusetts 0mcial Use Only Department of Fire Services PermitNo.- BOARD OF I 'RE PREVENTION REGULATIONS Occupancy and Fee Checked V. 1/07] Leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 27 C 12.00 (PLE,MPRINTIN)NKORTYPEALLINFO TION) Date: 5C27 City or 'Town of: Inspt By this application the undersi ed To the ecr of Wes. gives no ' e of ' or her intention toper orm the�icalwrkd below. Location (Street c& Number)4S7 A ('1 e O Owner or Tenant fl �--� Owner's Address T I tiz� Afj I CX)(--) Telephone No. ` Is this permit in conjulictioAffith a building permit? Yes Purpose of Building NO EJ BLDG PERMIT # Q Utility Authorization No. Ezisting Service Amps / _volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / j Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity 1 Lotion and Na ure of Proposed Electrical Work: cc�lc c- —KD�Et ?�� k . )(-- 0 c Completion of the following table may be waived by the Ins ector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total. No. of Luminaire OutletsTransformers KVA, No. of Hot Tubs Generators KVA S _ No. of Luminaires Above In- o. o mer enc z wimming Pool rnd. rnd. 0 Batte Uni g y g tin g No. of Receptacle Outlets 5 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and �2Initiatin Devices tl No. of Ranges No. of Air Cond. OZTotal Tons No. of Alerting Devices No. of Waste Disposers Heat Pump 117!!' uTons KW No. of Self -Contained Totals:................................................................._. Detection/Alertin Devices ( t No. of Dishwashers Space/Area Heating IOW Local ❑Municipal I J No. of Dryers Heating AppliancesConnection 1:1 Other Security SysteW�O ms:* ' No, of Water No. ofo. No. of Devices or Equivalent Signs Ballasts allas Data Wiring: is No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP g Telecommunications Wiring: OTHER: No. of Devices or Eauivalent I (O 0M �Ittach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectrical Work: �v/��.�/ Work to Start: (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule X 0, and upon completion. INSURANCE CO RA E: Unless waived b e owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins ce including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such Covera is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) d cert, under P e ai �snd penaltiess ofperjury, that the information on this application is true and comp&t, FIRM N SJR Licensee: LIC. NO.: 1^� I �� t\ Signature LIC. N ilf dyes abl er ` xe "in h 1' a ell ,IirEa�l, t �� ^ r Address: (/ t5 (( ^ �[ «� 4l Bus. Tel. No *Per M.G.L. c 147, s 57-61, security work requires Departmenpub hc Safety "S" Licen Alt. LIC.1oT0.: 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 (checo k ne) [] owner ❑owner's agent. Owner/Agent Signature Telephone No. pE RMIT FEE: $ GG 1.A .L ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOT G SMALL 2. FINAL INSPECTION: Passed — A Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: 2 - (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - ( ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] 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.Acciclents Office of Investigations 600 Washington Street Boston, MA. 0211.1 www.masss.govIdia Workers, Compensation 1 suxance Affidavit: Buitlders/Contractors/JEleciricians)Pluzmbexs uplicant baformation t . - Please Mnt Leaibll NaMa (Business/Organization/Individual):, Address:—FO O F� Q I, CAC(S77 O D `[ l Phone #: Qa � __� –7 9 cic6E Are yo employer? Check he appropriate box: L am a employer 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 atta6ed sheet. i ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We area corporation and its required.] officers have exercised their 3. ❑. I 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.] i 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. El Plumbing repairs or additions 12. F1 Roofrepairs 13.❑ Other 7Any applicant that checks box #1 must also fill outthe section below showing their workers' compensation policy infonnation. T Homemyners 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. lam an employer that isprong workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Nam Policy # or Self -ins. Lic.1#: rob Site Address l Z.,9 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 ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby c rtify�i ^der the pains andpenalties o perjury that the information provided ribove is true ancorrect. C,\ 11 . Q0 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense Issuing Authority (circle one): X. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.2lumbingfnspector 6. Other C ontactPerson: Phone Location 7(5/ / No. Z;oey Date I NORT►, TOWN OF NORTH ANDOVER It - , � -1 .. 9 Certificate of Occupancy $ bis' Eta Building/Frame Permit Fee $ �r SACNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 55.3 1 Building Insp yt&r G �s 2i H M z " M — z > ,n' Ln O a r r in in in G � a • > — — > — i ? •• m ! m Win• M z > G M Z Z Y > z G C Z > — m w Q COD O Y O G — Y ^' m M ~» _ 0 •- o Cl) R7 _ 2 M r _ v Z O z7 n > n � O J c N CIO C4 to to M M N y O n n O n n O n n O n O Z p n n o z . O � Ol 'n O on -, -'' - = n G n G' o ^ r En M rn rn- M y M r" a _ n? z z cn - n z` n ti r '^ m rte, v p � G M ui M zt � v m 2 Ln �] My J _ � N � z rnEn n u *W TWPL F'4:Z.06 k* ** TUTAL PAIAE.0-1 *.f tz rn y v ** TUTAL PAIAE.0-1 *.f BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with.the provisions of MGL c, 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: U Location of Facility V Signa e 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 ✓fze. �o�ivr�wouuea�� ¢� /�� •GEPARTRENT V PUBLIC SAFETY CGk.STRUCjLON SUPERVISOR II�cP'SE (�� ijtirIOfi: FvPl(8S: 4:f th di; tP: f . 0 24j29 i,3,'' r,gSC R85tClC'?C�-lo: CIAUOUJ 3EAU[ioIN WEST!4TaSTE?: IN MERR., IAi.. Location: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02191 Workers' Compensation Insurance Affidavit C-4. Please Print City Phone 71 am a homeowner performing all work myself. 711 am a sole proprietor and have no one working in any capacity Al-ra-m an employer providing workers' compensation for my em loyees working on this job. Company name: 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 ce�jifj#nder the pains and penalties of perjury that the information provided above is true and correct. Signatu Print name Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact # ❑ Building Dept ❑ Lincensing Board ❑ Selectman's Office ❑ Health Department ❑ Other Cl) m M m m 0 m COP) 10 Cl)CD Z CD o a. r d d CD .o 0 o p CL r�•F CD o E O cm CD CA 'C Co 0 w d d 0 -o Cl) c 0 c CO) E C) CD 0 rrt CD v CD H' CD CO) CD O CD 0 C CD O = C• y O w Q N G p m y mp m CD C7 ct.m yn C, Z of -i = m m CD a d p m N O -1 O _ :Cg5 m m CD to o p Z CO OOZ � C N • CL �+ d w CD c CD , ��-- CL CD. G ca N N d ;�►G oCL c a 0 N �7 C : .11:va N ,.�p _? N H m � N CD d m :�1 O O CD CD y a CD WCD CD W :d:C d lo! � o.� ii n� Q ': C CD c CD CD = ' = m CD, F w C/) w • " �+ d w � m � w 00 Z w j.j. a G d COD 'O cp � O � d o rfjx iJ &mom r 0 c