HomeMy WebLinkAboutBuilding Permit #740-2011 - 44 CASTLEMERE PLACE 5/4/201171/®- Via//
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
—kZepair, replacement
❑ Demolition
' E. Septic p Well
❑ Water/Sewer.
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
PROPOSED USE
Residential
ne family
❑ Two or more family
No. of units:
❑ Assessory Bldg _
❑ Other
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
El Floodplain ❑ Wetlands ❑Watershed
DESCRIPTION OF WORK TO BE PERFORMED:
r7//
" 0 6 L
Identification Please Type or Print Clearly)
OWNER: Name: �����yy"�LIA ���'� Phone: 9Z? Y30
Address: _
Phone: S
CONTRACTOR Name:
Address:
Ex . , Date:
Sup ervisoes.Construction License: P
Home,lmproveriient License`
�� oZ. /> Exp. Date:: ova
ARCHITECT/ENGINEER Phon
Address: Reg. No
FEE SCHEDULE. BULDING PERMIT -7$12-00 PER OF THE TOTAL ESTIMATED COST BASED ON
$125.00 PER S
LA-
Total Project Cost: $
l'7 v FEE:
f
Check No.: Receipt No.:
NOTE: Persons contracting with u e ' t ed contr ctors do not have access to the 9ug
Signature of Agent/Owner.
Signature of
I
Location
No. 7y0 - -9.0 Date
lget, TOWN OF NORTH ANDOVER
Check #
2412
Building Inspector
9
Certificate of Occupancy
$
s�CN�s <�'
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
2412
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swi nming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
7>D -PW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Tempbumon site yes no'
Located at 124 Mair" Street
Fire Department signature/date
COMMENTS..
Dimension
Number of Stories:Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of deter lova ion, mast or service drop requires approval of
Electrical Inspector YesNo
DAN(aER Z®Y�E LITER�+Tl1RE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
Doc.Building Permit Revised 2010/october
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers -Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Flo or/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
'®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
]l_n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
mmust be submitted with the building application
Doc: Building Permit Revised 2008
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XNThe Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
t ::'• ' 600 Washington Street
`s 01 Boston, MA 02111
r 1- www.nxass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1-C. 61: � lJ% ' � j V—
Address:-
City/State/Zip: &65:6 A
/JW Phone #: h U3 %Sl f1
,x3.3
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. g I am a general contractor and 1
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. 1
7• ❑ Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition.
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
9. n Building addition
required.]
officers have exercised their
10.E] Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.Q Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.0 Roof repairs
insurance required.] t
.employees. [No workers'
13 ❑ Other
comp. insurance required.]
*Any applicant that checks bo) # 1 must also fill out the section below showing their workers' compensation policy information.
t €iomeowners 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.
! am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
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 DiAkr—�nsurance coverage verification.
1 do hereby cert der the painsand ndltieF oof p ry the information provided above is true and correct
Signature: Date.
Phone #: L40 3 - -7,r-5;— / —5— 3 -5—
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 #:
I CERTIFICATE OF 1..11
THIS
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MUM"
A MATTER OF INFORMATION ONLY AN
CERTIFICATE DOES NOTAPFlRIIIAYIVEJ.Y INZ NEGATtYELY AMEND, EXT
BELOIN. THIS CERIIFICAYE OF INSURANCE DOES NOT CONSTITUTE A t
Ri=PRESENTATM OR PRODUCER AND THE CERTIRCATE HOLDER.
IMPORTANT: ff the cute holder is an ADDMONAL MWRFA the poli
terms and toncftons of the policy, certain pdiitles may require an ®nears
cartificata hoMw In Iieu 0f with andorsernent(s).
ALPHA INSURANCE AGEl NCY. MC.
B48 CENTRAL ST 1st FLOOR
LOWELL AAA 01652
CENA CONSTRUCTION
32 CONGRESS ST # 01
MILFORD AAA 01757
508.519-0529
OPIRTIFICATE
3 CONFERS NO R%*ITS UPON THE CERTI $
+;ND FC � OR ALTER TAFFORDED
ONTRACT SETYI Fm T'HE ISSW NG INSURER(S),
,ypes) must be endarso. N SUBROGATION IS WAIVIM. su
:meat. A btat®ment 00 This tcfdftM does; iva confer rights to
C+TPZT EDINA BRAGA
R E 9T8 459 4547 978 459 6131
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INSU>;r:R A:VVESIERN WORLD INSURANCE COMPANY
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THIS 4S TO C8KM 'IWT THE POLJCIES OF INSURANCE LI8TEI? BELOW HAVE BEEN ISSUED TO I Mt LNbUKbu MUMU ACV= r JF% I "v- lv--- 1.:- -
INIXCATED. NOTWITHSTANDING ANY 119QUIREMENT, TERM OR CONDITION OF ANY CONTRACY OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
0ORTEICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN
IS SUBJECT TO ALL THETERMS,
1 p(CLUSIONSAND CONDITIONS OF SUCH POLICICS, UMIIS SHOWN MAY HAVE BEEN RCOUCED BY PAID CLAW.
'�p1: OF 15 P POLICY DIL►AtoER
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DESCRIPTION Ou OPERATIONS Dery
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T
GAN OF OPERATKMI LOCATIONS I VEINCLES IABNA ACORD 1(1, AddMowl Ramaft SrdWMe, If MM Spam im gMdr +d)
RJ TCIALSOT ROOFING AND CONTRACTING
8 JOAN AVF
HUDSON NH Ml
PAX :003-525-4482
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NCMCE WILL BE DEUVEtED IN ACCORDANCE
WrrH YKE POLLCY PROVISIONS.
91
All rights resmed.
Talbot
MA. H.I.C. REG # 157288 Roofing & Contracting
LICENSE # CS SL 101775 Residential, Commercial & Condominium Roofing Solutions BBB
[� — _
NAME: {d Q , C41 ADDRESS:
HOME PHONE #: 971F y3 U �� r CELL #:
EMAIL: ' "//i7✓Dd CA- 101(-
1. DESCRIPTION OF WORK: 3 `.IP, L/%,j�r ,� i� r� �U�t-per ���-T &1%D _-
2. Install tarps from roof to ground to protect the house & landscaping'.
3. Remove existing layers of shingles and dispose of them properly.
4. Inspect all sheathing for rotted or deteriorated wood. If new plywood is needed, it will be an.additional
$ 2.25 per square foot. If new boards are needed, it will be $3.75 per foot additional.
5. Apply feet of Ice & Water to all eaves and feet to all valleys & around any penetrations.
6. Apply Roof Top Guard 15 Ib. felt paper to the remaining roof area.
7. Install Heavy Duty 8 inch drip edge to all eaves and rakes. Color to be: White - Mill - Brown - Copper
8. Install new pipe flanges to all existing pipes.
9. Install a ZT year- Certainteeed-L-ands-cape AF0iReettw-aI-Shingae per manufacturers specifications. All shingles
will be nailed using 1 1/4 inch galvanized nails. Color to be:
10. Install Shingle vent Two ridge vent to.a.lI ridges to ensure proper ventilation.
11. Option to install soffit ve�N�O7ew
S �NO.� Quantity: A) 1 Color:
12. Re -Lead Chimney . YES / lead will be sealed with Geocel.
13. Worksite will be cleanedon a daily basis and all areas will be gone over using a 3 -foot magnet.
14. All necessary permits will be the responsibility of Talbot Roofing & Contracting.
15. Talbot Roofing & Contracting will supply customer with Liability and Workers Compensation Insurance
Certificate prior to any work being performed.
16. Upon completion and payment in full,your new roof will have a workmanship warranty for a period of TEN years
issued by Talbot Roofing & Contracting and 2> years honored by the shingle maufacturer for material defects.
17. Any changes to the specification will be'executed by a written change order and will become an extra above
and beyond the original contract price. Talbot Roofing is NOT responsible for attic debris.
Note: This proposal may be withdrawn by Talbot Roofing, if not accepted within 30 days!
TOTAL JOB COST:
Price includes all applicable discounts.
COMMENTS: �/Ul GC/Os�/� 7'`l� /�/��.�-% 14ef r/,e D 7- 6444 r-�
TZ,f Iv -7- si 0' �- a
ACCEPTANCE of PROPOSAL: The above prices and specification are satisfactory and are hereby accepted. You are
authorized to do the -work as specified. Please sign a copy of this contract and send back to me along
with a $500 deposit. Balance is due upo
will be charged on past due acs over 30 day
Authorized Signature:
THANK YOU
** Afinance charge of 1.5% per month (18% per year)
`" Date:
ING TALBOT ROOFING & C6N 4ACTING
Talbot Roofing Contracting * 8 Joan Ave, Hudson NH 03051 * 603-755-1535 or 1-888-755-1535 * www.talbotroofing.com
I . The proposal pertains to services provided by Talbot Roofing & contracting.
2. Payment is due upon completion at our office in Hudson, NH. Payment not received within 30 days may be deemed in default. In the
event of a default, interest shall accrue from the date of default at the lesser of a rate of 1.5% per month (18% ANNUM) or the maximum
allowed by law, with a minimum charge of ($5.00) per month. Customer agrees to pay all necessary cost, expenses, legal fees and
amounts due if this account is tendered for collection.
3. Proper installation of the roof system may require replacement of existing flashing. During such replacement, siding adjacent to this
flashing, which has deteriorated, may crack, break or tear. Talbot roofing will make every reasonable effort to avoid damages, but will
not be held responsible for any consequential damage to the siding.
4. During the application of the roof system, vibration from the roof may be transmitted throughout the house. The customer assumes
responsibility for all objects hung from exterior and interior walls and from ceilings and soffits.
5. Talbot Roofing is considerate of the customers gardening, flower beds, and landscaping, but due to the nature of a roof system
installation, some damage may occur. We attempt to minimize any damage, and will NOT be held responsible if any damage occurs.
6. Customers shall not walk under work area while roof work is in progress. Construction site is a danger to person(s) on the ground from
falling objects.
7. In the event that Talbot Roofing removes a satellite dish or antenna from said roof to complete work, the homeowner shall be solely
responsible for hiring a qualified technician to re -install and align such equipment. Any cost arising from such work shall be the sole
responsibility of the homeowner.
8. Talbot Roofing wan -ants its roof system to be free of leaks for the duration specified. Talbot Roofing assumes liability for repair of any
installation workmanship defects causing leakage. Homeowner agrees to hold Talbot Roofing harmless for any interior or exterior
damage, to include environmental damage including "mold" resulting from water leakage. Talbot Roofing shall have no liability beyond
repair of said roof. Roofing material is warranted by the manufacturer under a separate warranty which is issued to the customer upon
payment in full.
9. Talbot Roofing is NOT responsible for ice dams and any leaks that may occur from the ice dam. Ice dams are caused by excessive heat
loss through windows and or skylights, as well as impropef insulation in your attic.
10. All warranties are transferable after payment in full.
11. RIGHT OF CANCELLATION: Homeowners may cancel this agreement if it has been signed by the parties involved, if in writing, to the
contractors office no later than midnight of the third business day after signing.
12. Permits: The contractor shall inform the Owner of any and all necessary permits for the work. It shall be the obligation of the Contractor
to obtain said permits. Homeowners who secure their own permits shall be excluded from the guaranty provisions of the Home
Improvement Contractor Law.
13. REQUIRED DISCLOSURES: The disclosures set forth in this paragraph are required if the work constitutes residential contracting. The
owner acknowledges having the opportunity to read the following disclosures prior to signing this contract.
ALL CONTRACTORS AND SUBCONTRACTORS MUST BE REGISTERED BY THE CHIEF ADMINISTRATOR OF THE
BOARD OF BUILDING REGULATIONS AND STANDARDS, AN AGENCY WITHIN THE EXECUTIVE OFFICE OF PUBLIC
SAFETY, ANY INQUIRIES ABOUT A CONTRACTOR SHOULD BE DIRECTED TO SUCH CHIEF ADMINISTRATOR. THE
REGISTRATION NUMBER OF THIS CONTRACTOR IS 157288. THIS CONTRACT DOES NOT CREATE A MORTGAGE OR
SECURITY INTEREST IN THE PROPERTY, HOWEVER, THE CONTRACTOR AND OTHERS PROVIDING LABOR OR
MATERIAL TO THE PROPERTY HAVE RIGHT UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 254 TO RECORD
A NOTICE OF CONTRACTS AS TO THE PROPERTY AND TO OBTAIN A LIEN ON THE PROPERTY TO SECURE
PAYMENT OF AMOUNTS OWED TO SUCH PERSONS AS A CONSEQUENCE OF THIS CONTRACT.
ATTENTION HOMEOWNERS
Talbot Roofing recycles their roofing materials. Please do not place any trash or debris in the dumpster while on your property. Any
and all trash will be removed from the container prior to pick up and additional charges will be applied.
RIGHT OF CANCELLATION:
Please sign & return to our office no later than midnight following the third day after signing.
CUSTOMER:
DATE:
CUSTOMER: DATE:
Boston, Massachusetts 02116
Home ImprovementEll L"o-11K
actor Registration
RJ. TALBOT ROOFING & CO
ROBERT TALBOT
8 JOAN AVE.
HUDSON, NH 03051
.CAI 0 5oM-04/04-Gi01216
Registration:
Type:
Expiration:
157288
Ltd Liability Corporation
9/20/2011 Tr# 288667
date Address and return card. Mark reason for change.
Address E] Renewal 0 Employment E] Lost Card
llassachu%ctts - Department of Ptiblic safet%
Roard of Building-, Re,_-ulaiions and Standards
y Construction Supervisor Specialty License
License: CS SL 101775
Restricted to: RF
ROBERT TALBOT
8 JOAN AVE
HUDSON, NH 0301
E ..tttnt7�.i.�+trr
Expiration_ 12/13/2012
Tr=: 101775
b
100169
Date ..... 1.11.3.115 ....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�8 V
"This certifies that ........... L ....... 4 ....... P ......................... ....................... ....... . ...........
has permission to perform 4-0,3 ..... (-e ",-'a � A
...............................................
plumbing in)the buildings of .... (,tk .........................................................
at .... . .... .......... North Andover, Mass.
Fee ... Lic. N02,1m6 . .....
......... e� ............................................................
PLUMBING INSPECTOR
Check# ;1�"
&44'f3-jSv„ k\�oji�j
s"
SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM
�aN_rOWNERADDRES
PLUMBING WORK
G% MA. DATE_ /" I�—%S PERMIT#
DDRE S >� I'L- OWNER'S NAME ( � U0 jd4e!f2
P'- Q'�' l -2�eP� TEL FAX
TYPE OR Y. TYP : COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ,
PRINT NEW: ❑ RENOVATION: ❑ REPLACEMENT: ,� /
CLEARLY Lam' PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES 7 FLOOR-- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER t
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
.
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
`WATER HEATER ALL TYPES
WATER PIPING
OTHER
r1have
INSURANCE COVERAGE:
a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142.• Yes] No ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® 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
Massachusetts General Laws, -and that my signature on this permit application
waives this requirement.
❑ ❑
Signature of Owner or Owner's Agent CHECK ONE BOX ONLY: OWNER AGENT
I hereby certify that all of the details and information I have submitted (or entered) regarding this 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME Peter J. Crane SIGNATURE
LIC # 21805 MP ❑ JP] CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street
CITY Haverhill STATE ITA ZIP 01830 EMAIL annacrane.ac@verizon.net
TEL 978.771.1155 CELL 978.771.1155 FAX \
Date..... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
'Ibis certifies that ... V�7e
..... 1 ................. a4 ............ ...............................
has permission for gas,installation ....... . ....................................e.w.c.1-4
....................
�w C
in the buildings of .......... ) .................................................................................
. ........ ...
0a -w
at ............... F..) .4 ........................,./.North Andover, Mass.
Fee... Lic. No.. .. . .................................................
GASINSPECTOR
Check #
1
-� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA. DATE /'— ^-J PERMIT# 7/z (—
JOBSITEADDRESS OWNER'S NAME
'G OWNER ADDRESS: —ar
TEL:FAX
TYPE OR
PRI11'T OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ElRESIDENTIAL
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: []� PLANS SUBMITTED: YES ❑ NO ❑
FIXUTRES 7
FLOOR- Ssmt 1 2 3 4 5 6 1 7 8 L 9 1 10 1 11 1 12 1 13 1 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
y
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES] NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted (or entered) regarding this 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 applica ' n will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTERNAME: I Peter J . Crane LICENSE# 21805
SIGNATUR
COMPANYNAME: I Crane's Plumbing & Heating ADDRESS: 70 Douglas Street
CITY: I Haverhill STATE: >~IA ZIP:01830 FAX
TEL: 1 978.771.1155 =CELL:j 978.771.115 EMAIL:I_.annacrane.ac@verizon.net
MASTER 0 JOURNEYMAN ® LP INSTALLER ❑ CORPORATION ❑ #PARTNERSHIP ❑ # LLC ❑
The Commonwealth of Massachusetts
- DepaptmentofbidustriglAccMiks
Office of Investigations
600 Washington Street
.Boston, MA 02111
www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Bupders/Contrac•
Name
M
Address:
City/State/Zip. _��,e Phone #:_ 7'
Are you an employer? Check the appropriate box:
1. ❑ am a employer with
4. I am a general contractor and I
mployees (full and/or pax- time) *
have lvredthe sub -contractors
listed on the attached sheet
2. I am a sole proprietor or partner
ship and`have no.employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance,
5. ❑ We area corporation and its
[No workers' comp. insurance
officers have exercised.theix
required.]
3111 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c.152, §1(4), and we have no
in.surancerequired.] ?
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction f
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.[] Electrical repairs or additions
II.[] Plumbing repairs or additions
UP Roofxepairs
13.❑ Other
,Any applicantthat creeks box4l must alsofill out the section bel6w showing their Workers' compensation policy information.
Homeowners who submitthis affidavit indicatingthey ire domit a new affidavit indicating such.
ing allworM and then hire outside contractors must sub
TContractors that cheAthis 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 Polley and job site
information.
insurance Company Name: -
Policy 0 or Self* -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensationToliey declaration page (showing the policy number and expiration crate).
pailure-fo secure Covera e_as re uixedunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a
g _gym -
fte ilil $1;500.00 andler-oneVear imprisonment; as well as ezy�-penalf�es-na the, -form of a STOP WORD ORDE�t and -a Tina - v
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 liereby cert& under Lite pains and penalties ofperjury that the information provided above is true and correct -
3114
Siemature• �--_- Date �./le
Phone #:
Okla/ use only. Do not write in tliis 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. CityNowu Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other -
Phone
Information and Instructio-
ns
Massachusetts
General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an efilployee is defined as"...every person in the service of another under any contract o0ire,•
express o:rimplied, oral orwritten.."111
An employees defined as "an individual, partnership, association, corporation ox other legal entity, or any two ox more
of the foregoing engaged in a joint enterprise, and including the Iegalrepresentatives of a -deceased employex,.ox the
receiver oririistee o£an, individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having notmoxe Than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage req. -aired."
.Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence o£compliance with the insurance
requirements of this chapterhave beenpresentedta the cQutracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), addresses) amdphonenumber(s) along with theircertificate(s) of
Insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other that the
members or partners, are notzequired to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial
Accidents for couffimation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department o£
Indusirfal Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
Self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be -sue to fill in the permit/license number which will. be used as a reference number. In addition, an applicant
that must submit multiple pexmithicense applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Sob Site Address" the applicant should write "all locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as pxoofthat a valid aff idavit•is on file for future permits or licenses. Anew affidavit must be filled out each _
-- year W-hereahemeowner-orcitizenis-obtauungalrcerxse_or_permitnotielated-toanybusinessoeozriinezcialvenfiire>
(x.e, a dog license orpermit to burn leaves eta.) oaid person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and shpuld you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone an:d fax number:
The ComMonwea tlt of assa.,I,v.:sPifs -
Y?9par(M0 t ofJ dud al .fi ccidenta
Ofte QfZmstigat[ na
600Wasbi won Sf=-t
BoStA MA 0.2111
TO. # 617-727-4.900 e 406 or 1.877,MA.SSM
Revised 5-26-05 FOR 617-727-7749
' wt�Vcr•�a�s,g4v�411a .
ERH I LLMA 01830-6::741
.................
Date ...�......�, ......
NOPTH ,�
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INS
O
f�A
S
�^ - V'�....................
es that ...........:.......
This certifi ,(1 P.�.....
as installation ......%..:........!:�..... ....
d Permission for g D ...................... .
r
has v. U,� n ........................................ Mass.
s of .................... , North Andover,
i in the building A -A.. ......... .
e............
.................:......
at ...........................:.. ��
...................
^ti ••••••�••"' GAS INSPEC70R
G — ......
Lic. No...........
Fee . � .............
t Check it ,
a�
M
ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
0 U 21� MA. DATEPERMRESS ��-�/��OWNER'S NAMETELFAX
TYPE OR TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ®�
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES 1 FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
rhavea
INSURANCE COVERAGE:
nt liability insurance policy or itssubstantial equivalent which, meets the requirements of MGL Ch. 142. Yes] No ❑
KED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWTY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BONDURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, -and that my signature on this permit application waives this requirement.
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this 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 provision of the Massachusetts State Plumbing Code an7Cha er142 of the General Laws.
PLUMBER NAME Peter J. Crane SIGNATURE
LIC # 21805 MP ❑ JP Q CORPORATION ❑ PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street
CITY Haverhill STATE 11A ZIP 01830 EMAIL annacrane.ac@verizon.net'
TEL 978.771.1155 CELL 978.771.1155 FAX
\1)
.
U1.
so
e
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY n. MA. DATE I j/ ' PERMIT # JU4O 6—
JOBSITE ADDRESS -[CQ C- OWNER'S NAME Cp
G OWNER ADDRESS:
c/1zBl-e_ = TEL: I FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ®l PLANS SUBMITTED: YES ❑ NO ❑
FIXUTRES 7 FLOOR- Bsmt 1 2 3 4 5 1 6 1 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liabilijj insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES] NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY F] OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑
hereby certify that all of the details and information I have submitted (or entered) regarding this 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
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7 _
PLUMBER/GASFITTER NAME: er J . Crane LICENSE # 21805 �� �J✓L����
SIGNATURE
Pet
COMPANY NAME: Crane's Plumbing & Heating ADDRESS: 70 Douglas Street
CITY: Haverhill STATE: FFIAI ZIP: 01830 FAX
TEL: 1 978.771.1155 CELL: 1 978.771.115 EMAIL: annacrane.ac@verizon.net
MASTER 7 JOURNEYMAN ® LP INSTALLER ❑ CORPORATION ❑ #=PARTNERSHIP 0 # LLC ❑ #
The Commonwealth of Massachusetts -
Department of IndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.mass:gov/dia •
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lep-ib,ly
Name (Business/Organization/Individual):
Address: 7" O
City/State/Zip:
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ l I am a employer with
4. F1 am a general contractor and I
6. F1 Now construction F
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have ned the sub -contractors
listed on the attached sheet. ?
7• ❑ Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. E] Building addition
[No workers' comp. insurance
5. 0 We are a corporation and its
10.E1 Electrical repairs or additions
required.]
3111 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.0 Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roof repairs
insurance required.] t
employees. [No workers'
13. ❑ Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t -Homeowners who submit this affidavit indicating they n"re doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors 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
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 wellas civilpenalties 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certio under the pains and penalties of perjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completer) by city or town official.
City or Town:
Permit/License #
x d / .Cl / i
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
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,-
express
ire,-express or implied, oral or written."
An employer'is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced.acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. 1f an LLC or LLP does have
employees, apolicy is required. Be advised that this affidavit maybe submittedto the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Job Site Address" the applicant shouldwrite "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Gom onwealthofMrossachvsetts
Department ofldusttial .Accidents
offloe o£I�estiation
600 waftpa Sfxeet
Boston, MA 021.11
Tel # 617-727-4900 at 406 ox 1-577-.MA.SSAFE
Revised 5-26-05 Fax # 617-727-7749
www ma %govkdia
•
Im
1
Date.... ..............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....................... ............ ....V............J ..
has permission to perform........... . C, .....................................................................
wiring in the bu . ding of.........
( -m 0
-!kk �
...................................................................................................
orth Andover, flMvla
af .....................................
Fee ... k.A . ....... Lic. No..I.Vl . .....
.................. .. ..... .......
ELECTRICAL INSPECTOR
check,, 84q I
IPP
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1a '
Occupancy. and Fee Checked
[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), 527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: /� —� �✓"/s^
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)ys Gv4S! �1?GLl`� lf'64 cg
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Com letion o the olio itabs b ' d b h I
No. of Recessed Luminaires
I n
No. of Ceil: Susp. (Paddle) Fans
a may a waive tens ector o Wires.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
o. o mergency Lighting
Md. rnd.
BatteryUnits
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. fDetection
i
ti tinDev
Ies
No. of Ranges
No. of AirCond. Total
No. of Alerting g Devices
No. of Waste Disposers
Heat Pump
Number
Tons
KW
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 Water
No. of No. of
No. of Devices or Equivalent
Heaters KW
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
c_T
Attach additional detail ifdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (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 M BOND ❑ OTHER ❑ (Specify:) `41
I certify, under the ains and enalties ofperjttr ,that he 'nformation o this application is true and coniplete.
FIRM NAME: /4i!� LIC. NO.: J Q f SS e
Licensee:/moi !� /zo` Signature L . NO.:
(Ifapplicab ed enter `exe t" in the license yin r ine� ,y� OO Bus. Tel. No.:
Address: S / S O� Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work re uires Department of Public Safety "S" License: Lie. No.
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. iZ4Z-
Owner/Agent
Signature Telephone No. PERMIT FEE: $ �"
... E�ECTAiCA� ?�ER1�ST' i�®, �I�PLCTZOI�l' .�Pi��7C:
ELEC"IC L I SPECTOR •- .
Passed [) VaUed--[ 1 Pe -5 .peciion regwirecT($50.00) - X j
Piaspector. coJoatzteufs:
a is. •' .
_ t t ^. • S.
(Inspectoxs' Signature -no idtiais) Date
2. .VMAL IT8PY ZObI;
Passed- [ ] Fallecl—[ ] PW bspection required ($50.00) -• [ �
Inspectors' comment
_2 r/
(f&&ctors' Signa a -• n 'tials) Date
3. TJMFR GROUM )NUECTION:
Passed—[ ] Iaiiec)--[) Re-inspectionaeguixeti($50.00)�[ ]
Inspectors' comments:
(Inspectors' Signature •-no Htfals) Date
.I) OO:?, T'A.G,9ARE TO DE ED OUT AND LEFT ON SATE R THE AM TO 3E INSTECTUD ISNOT
ACCESSIBLE AND A RE W'SPECTZON OF §50.00 IN TO DE CHARGED.
I
r
The Commonwealth of M'assachasetis -
Department of IndustYictiAccr�'er�ts
Office of Investigations
600 Washington. Street
Boston.' MA 02111
-www.mass govldia
Worker$, Compensation Lmurance Affidavit: Builders/ContractorslEX dracianPleat � ��umb r
gly
Applicant Wo r nation
Name (Business/Organization/tndividud):
Address-
City/State,
/Zip: Phone 0;
Are your an employer? Check the appropriate box:
4. ❑ I am a general contractor and I
1. I am a employer with
employees (full and/orp
have nod the sub -contractors
2. [�' I am. a sole proprietor or Partner-
listed on the attached sheet. r
These sub -contractors have
ship and'have no employees
working forme in any capacity.
workers' comp. insurance.
[No workers' comp. jnsurance
5. F1 We area corporation. and its
Officers have exercised their
xequired.]
3. ElI am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c.152, §1(4), and we have no
employees. �Noworkers'
o insuran.cexegaired.j i
comp. insurance required.]
Type of project (required):
6. [] New construction F
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing. repairs or additions
12.0 Roof repairs
13.❑ Other
xA applicant that checks box#1 must also filloutthesectionbelbwShowing
theirworkers'compensationpolicyinformation
t•H&meowners who submit this affidavit indicatingthey are doing allworlc and then hire outside contractors must submit a new affidavit indicating such.
?Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
jam are employer that is providing workers' compensation insurance for• my employees: Below is the policy anti joh ,site
information.
Insurance Company Name: l ��
Policy # or Self ins. MG.
Expiration Date:
Job Site Address- City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or onc7-year imprisonment, as wellas civilpenalties in the form of a STOP WORTS ORDER and a fine
ofupo $250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office -of
Investigations of the DTA for insurance coverage verification.
T,,-o,b er fy ad the ai enalties ofperjury that the informationprovided abovve is true an'carre �Date• /3 G�� D
Official use only. Do not write in tliis area, to he completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle bre):
1. Board of Health 2. Building Department 3. CiiylTowa Clerk 4. Electrical Inspector 5. Plumbing faspector
6. Other
Contact Person: - Phone
Information and Instructions �r `
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of biro, •
express orimplied, oral or. written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local lie -ening agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the p erfornnance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have beenpresentedtathe contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking tho boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(os) and phone numb er(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have
employees, apolicy is required. De advised that this affidavit maybe, submitted to the Department of Industrial
Accidents fo; confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumedto the city or town that thio application for thepermit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance, license number on the appropriate line.
City or Town Officials
Please bo sure that the affidavit is complete and printed legibly. The Departmenthas provided a space at the bottom
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one afixdavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant shouldwrite "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ?
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho Co qnw-m1th ofmlouachwotw
DapartmeatofWV5tdalAccidenta
offloe ofTuvesiigatio) '
EQGwawz pa koet
Boston, M -A. 02111
Tei, # 617-7.2' -4900 at 406 ox 1-$77-MASSAF;,
Revised 5-26-05 Fayd 617-727-7749
vwvw=,%govldia.
V,
03o4-2-21
�U 2012 Massachusetts EIeetmical Code Amendments 527 CMR 12.00 § Rule 8: In accordanee with theprovisions of M.G.L. c. 143, §, 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed a
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. 01 c. 166, § 32, as �d
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shalt be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits sha Lbe limited as to the time of ongoing construction. activity, and maybe deemed by-thoJuspector_of_W.ires abandoned_and.ir valid.ifhe_..
1 or she has determined that the authorized world has not commenced or has not progressed during the preceding 12 month period. Upon written
` application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certairpermits -and licenses concerning the use or development ofreal property. With
limited exceptions, the Act automatically dxtends, for four years beyond its otherwis a applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008_and extending"through August 15, 2012.
8-Permit/Date Closed: ,l 2.-1.4 *** Not04A
apply for new
it Extension Act -Permit/Date Closed: -57-- l2- ` / 9-^
v
l�
Date ..... I . /..:. 3'. .%.......
f NORTI{ 1
e41TOWN OF NORTH ANDOVER
MR
p PERMIT FOR WIRING
ACMUSf
This certifies that ................. V9�,�i/fi ��!'!J/........................................
has permission to perform ........� ...
..... —x` 1/.. ................................
wiring in the building ofC bar D
................................................................................
at ..��% ./�...... North Andover Mass.
/ 52.. E' ,>
Fee ...t.�............ Lic. No;V 3 ........ .............. ...... .../.... x ............
ELECTR[CALINSP CTO
Gheck # q�
Commonivealik- f Massachusetts
1UR99
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
=. Official Use Onl
Permit No. 16
Occupancy and Fee Checked
ev. 1/05] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 CMR .00
(PLEASE PRINT IN INK OR TYPE ALL FO AVON Date:
City or Town of: O / .017♦ vel To the Inspe orVoffires-:---
Bythis application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street &Number) �� L, 4.f '.41 f'.41 p%� p
Owner or Tenant �, fy� jyj ® Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
-- -r
No. of Ceil.-Susp. (Paddle) Fans
w —4r Vy ucC [/LY Or o n'hres.
o. of ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑- ❑
grnd. El'
o. o Emergency g g
Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. , of Switches
No. of Gas Burners
o. of Detection and
Lifflatine Devices
No. of Ranges
No. of Air Cond.Tons otall
No. of Alerting Devices
No. of Waste Disposers-
eat Pamp
Totals:
Number.
ons
o, o m -Couta
Detection/Atertina Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal E] Other
Connection
No. of Dryers
No. of Water KW
Heaters
Heating Appliances KW
No. of -- o. of
signsBallasts
Security Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Te1lecommumcations .n-mgg•
No. of Devices or u%valent
OTHER:
/ Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work b e Q (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NEC 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 %ov5age is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ( OND ❑ . OTHER ❑ (Specify:) 4 /j 4�
I certify, under the pains and�en o perjury at thein ornt°n on this appltcatron is true and complete:
FIRM NAME: �L!?4� �/$� BIf/f fG T - LIC. NO.:
Licensee:.
v%d Signature LIC. NO.. •
(If applieabk t -- is the license number line Bus: Tel. No. -A# -r7-
Address: /! ld 0� f /,/!��h�fD�� Alt. Tel. No.: D
*Security System Contractor License for this work, if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: lam 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
Signature Telephone No. PERMIT FEE :$ 40,04)
,a
.� The C^.ommonweafth ofMassachusetts
Depanwnt of-Tndvs&W pc ciderft
• • - Office of Investigations
600 Nrashinb%an Sftd
Barton, Md 02111
t: h:7t::tl�C� Q/L`:1'7Tll
1�'or;,
cers' Compensatioz, imiran•;c AldeAt: Build�ars/Coutraetors/Electricians/Plumbers
Name i- w;ncssiorpnizatioaladividual):of
.��/�
Address:
Ciry/State%lig: S�le� t Dpi Pthone #:
Arc you an employer? Check: the appropriate box: Type of project (required):
1. ❑ 1 am a �ttptoyawith 4. ❑ I am a general contactor and I
�lenses (tali and/or psci-tithe').: have bind the st6-ennbactors I 6. ❑New construction
2. dJ 1 am a sote proprietor or partner listed on the atached sheet 7- Q Rehzodeling
i
ship and have no tmtplovees Theats sub-contrac-uxs iurc8. [] DahoIilion ;
work�
working for me is any cii - eavloyew and live worts' g. � padding addition�
[No workers' comp. insurence comp. Wsuz M. :
requi�', 5. D We we a corporation and its 10.( leeuical repairs o* additions
3. ❑ I am a homeowner doing all work offices have exercised their 11.Q Phu &iag repairs or additions
o workws' right of exerM ion per MOLrep
airs
mh o ��j t c. 152, §1(4), and we have no 12.1-] ❑
employees. (No works' Odw
I
- *AsY Vp#cm9 that t lttxto; bax AI aunt stso fW out the suhw bdow shoabe urea wod=e coopmsWoa poic' bdbsuutia.
t Homoowc= why Submit this eRiio-4 indi:atia; &,7 am doing alt vm& and thea himoomidc oaausuaa anst SOWt a sumr aaMdank h4ca ft such.
twtACims that deck this boat must sundtod en adMaW sheat d owbil the ame of'dw =b-eomena mt and aaM Wbedwrorno:1x= amities have
=*tncm ifttu Wes h wo smptoy=% ftymud pv ida thdr wocaas' mop. p Ecy m ba
law an dwplo),er that it pr,ovii ft workers' compensation insurance for my employee& Below Is thePvhcy trod job site
information.
IM%Uunoe Company Nath;.:
Policy # or Self -ins. Lic. d: Expiration. Date:
Job Site Address: City/stat6%ip:
Attach a cops of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fnihtrc to accuse wvca%c as required under Section ZSA of MGL c.152 can lead to the imposition ofrrin incl penalties of a
fine up to 11,500.00 nad/or vasa -year imprisonment, as well as civil penalties in Bre form of a STOP WORK ORDER and s fine
of up to 5250.00 a day against the violator. Be advised that a C0P3 of this statement may be fmvaTdod to the Office of
invest Mons_of We_-J;klA fbr insiaacxre coverage verification.
I do thereby cert fy under the pains and p aloes ofpedury that the & jortnadon provided above true and eorred
��j . /
3�gnantre: '/i�iv( lata %� x
OVS4to
or Imm o,Jj',dd
City x Town: P13rttidl.ic�tat #
Issuing Authority (drde one):
1. Board ofHealtb 7- Bulltimg Department 3. Cityfl'own Clerk 4. Elechical Inspedor 5. plambing Inspector
6. L'tht-r
Contact Person: Phone A
V
PERMIT NO.:
UNIT NO.:_
woarh
Or .... ••,40
Town of
;�__<�+C''• NORTH ANDOVER
BUILDING PERMIT INSPECTION REPORT
—PROJECT: INSPECTION DATE:
FLOOR: WING: BUILDING NO.:
L46- CGLS �(ome-ke- L, K)
REMARKS: 0 () 6 C L4 &PI6
Vic) L 7�/ — �o — 6 73 2'
6 3 f\J vr, 16 , A Uve2 , Xoe-
Rew^ ILTa;Aeq rtz // /d'�_
Excavation - depth and soil conditions
Framing -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Footings and foundations and drains -
Insulation -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - rough -
Plumbing and/or gas - rough -
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Electrical - final
Plumbing and/or gas - final
Other:
Date:
Date:
Date:
Inspector
Inspector
Inspector
Fire Dept -
oil burner, tank, stove, smoke detectors
Final inspection
Certificate of Use and Occupancy
Date:
Date:
Date: —Cof 0#
Inspector
Inspector
Inspector
rorm Mb Action Press, otfo-iuuo
rt
'List of Professionals
Page 1 of 1
Home i Map ( Toolbox I Help
r
��'�ssc�Iezzs�Pis -
# flRfi P.i� .
':.srnrJ.€crrrs+�'1 li�'�' "1;ia+
Licenses fitting search criteria:�� �s
Profession equals Electrician
Last Name beginning with shanley
First Name beginning with thomas
Licensing
License
License
Board
Type
Number
Electricians
Journeyman
50063
Electrician
Electricians
Journeyman
27619
Electrician
Name City/State License
Status
SHANLEY THOMAS J. NORTH Current
ANDOVER, MA
SHANLEY THOMAS P. HYDE PARK, MA Current
Your search has resulted in 2 licenses
oma 1 Map I Toe 1 bax i H o I p
Division of Professional Licensure
239 Causeway Street
Boston, Massachusetts 02114
Phone: (617)727-3074 Fax: (617)727-2197
Please send your technical questions or
comments about this web site to
REG.WebMaster@State.ma.us
Disclaimer
Privacy Policy
Enforcement Process Glossary
./pubLicRange. asp?profession=Electrician&1Name=shanley&fName=thomas&city=&state=&zi-1129102
4—
Permit No.
V*4-f—s 4 P-#& 'S d4 Occupancy & Fee Checked
BOARDOF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date
To the Inspe6toVof Wim:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number Sf 4�W5rtrmEpf 1 )t)tl 1*u49pvE-,g o
Owner or Tenant
Owner's Address IS (f Pq S7 -L F— M re C 5T A)- fi%U 46 OF
Is this permit in conjunction with a building permit Yes 0 No Po,-' (Check Appropriate BOO
Purpose of Building_ VWity Authorization No.
E)dsting Service Amps voits Overhead 0 Undgmd 0 No. of Meters
New Service Wits Overhead 0 Undgmd 0
----AmpS No. of Meters
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work
Date.R.71
TOWN OF NORTH ANDOVER
PERM -IT FOR WIRING
This certifies that .... ...........................
has permission to perform. ..................... 1—L) .....................
.... ... .. .. . .. .... ........
wiring in the building of ....... ....... C-0.0 ... () ................................
... .. .... ..
at .
............. ;'r ............. i ................... e .............................. ..No Andover, Mass.
Fee ..............
....... . Lic. No............... ..............
Check # CA'C, t-1
ELECTRICAL NSPE , R
tL- too ce C' F6 -T 67) #W g,<'rmq�
I
§= NO =
:overage by checking the appropriate box
1,1we)
-
LIC. NO.
41LC�l LIC. NO.
L - J
ibstantial equivalent as required by Massachusetts
ant (Please Check one)
PERMIT'FEE
3578
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
54 6 ti I -f x ........................................
This certifies that 5 .................................................. .
has permission to perform ..... RIP (,v I r rub
.... ...............
wiring in the building of ....... �3. eh. . .... C.O.UI-0-C) ..............................
C-/ 5 C A��A i, -P W if, r �c ........... .
at ..................................................................... North Andover, Mass.
03 �i:*--'Je(� / fl4((4A—
J/
Fee ....... 3.Sr ... Lic. ...............
ELECTRICAL " ..............
Check #
Official Use
+
On
7r5 %Zn17�fnJ�%r$ Permit No.--. 3'�
'S-da# Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information)
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Date g / A
To the Inspe to of Wires:
Location (Street & Number _`/ �S^� L/L{
Owner or Tenant N l� �1 o
Owner's Address >� C /-2 S '�L G F ✓ J - A)~ /9V 00Lf ` 9( 06L
Is this permit in conjunction with a building permit Yes ❑ No 9 -"(Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters
New Service Amps Voits
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical
Overhead ❑ Undgmd ❑ No. of Meters
OTHER: fu %RE au; u-io & & -T- 'r ug /A.)s-T/gf-L a- 106c G/-e'.L so &W- '61eLmyii
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify)
(Expiration Date)
Estimated Value of Electrical Works 15 0 O - 67z)
ork to Start Inspection Date Resquested Rough Final
gned under the Pena es o
FIRM NAME .S/f�' �fP�ryury:
I� ry t -i 44 L f LCT'51 6- n LIC. NO. /' �i
�k ✓/ 6Eit11 C)1 /�O /Y '�r B
Address Aft Tel. No._
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance
General Laws. And ttvil ny signature
NO. r—'S-V66-5
on this permit application waives this requirement Owner Agent (Please Check one) i6°
VV�d ',Telephone No. / ! C- CXJ 23 MI PERMITTEES 4�6'l
of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑ In ❑
No. of Lighting Fixtures
Swimming Pool
gmd ❑ grnd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets '
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Di osal
No.
Pumps Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER: fu %RE au; u-io & & -T- 'r ug /A.)s-T/gf-L a- 106c G/-e'.L so &W- '61eLmyii
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify)
(Expiration Date)
Estimated Value of Electrical Works 15 0 O - 67z)
ork to Start Inspection Date Resquested Rough Final
gned under the Pena es o
FIRM NAME .S/f�' �fP�ryury:
I� ry t -i 44 L f LCT'51 6- n LIC. NO. /' �i
�k ✓/ 6Eit11 C)1 /�O /Y '�r B
Address Aft Tel. No._
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance
General Laws. And ttvil ny signature
NO. r—'S-V66-5
on this permit application waives this requirement Owner Agent (Please Check one) i6°
VV�d ',Telephone No. / ! C- CXJ 23 MI PERMITTEES 4�6'l
of Owner or Agent)
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