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HomeMy WebLinkAboutBuilding Permit #537-13 - 535 CHICKERING ROAD 1/28/2013Permit N0: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: "( IMPORTANT: Applicant must complete all items on this page PROPERTY Print MAP NO: PARCEL: ZONING DISTRICT: 100 Year Old Structure Historic District yes yes no - no; o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial 0 AI ation No. of units: ®'Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District' Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: W.JQ R v n 146 L1 6 Identification Please Type or Print Clearly) OWNER: Name: ArlrirPsc- CONTRACTOR Name: - wAr5 111 Supervisor's Construction License: Exp Home Improvement License:: Phone: aM�J ` -7fi Date: Date: l Ia© l ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: l-7 Receipt No.: 0-`11. NOTE: Persons contracting with unregistered contractors do not have access to the Paran f Sign to ureof Agent/O a ��� _ nature of contractor. 100 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 0 Stamped Plans ❑ Location tL No. r Datj Check #� 26119 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE.OF SEWERAGE DISPOSAL ` Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools A Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE APPROVED Reviewed on Siqnature 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 DPW Town Engineer: Signature': Located 3M Us ooa Street FIRE DEPA-RIMENT )= Te.'mp Dumpster on site yes no Located at :124 Mainstr6bt . Fire Department•sigriatureYdate ` COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA — For department use E3 Notified for pickup - Date Doc.Building Permit Revised 2010 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 ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) -10 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In 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 must be subm;tted with the building application Doc: Doc.Building permit Revised 2012 CONTRACTORS SPECIAL POLICY DECLARATIONS PAGE New Business Declaration UTICA FIRST INSURANCE COMPANY CONST n UTED IN OHIO AS UTICA FIRST INSURANCE COMPANY (MUTUAL) Direct Billed - Insured Home Office - 5981 Airport Road, Oriskany NY 13424 Mail Address- P.O. Box 851, Utica, NY 13503-0851 Policy Number: ART 5030301 00 Renewal of Number: NAMED INSURED AND MAILING ADDRESS { Number &rete' Town or City. y Zip Code 1 Agent 2712000 N & B GENERAL CONTRACTING ARMAND P MICHAUD INS AGY INC NICOLAS BRANCHINA DBA 105 HAVERHILL STREET 12 FARLEY STREET METHUEN, MA 01844 METHUEN MA 01844-9999 POLICY PERIOD: 12:01 A.M. Standard Time at the Location of Designated Premises. 08/09/12 08/09/13 From To Item Number Prot. Class Rate Group Const Description and Location of Property Covered 1 PR F Description: CARPENTRY Location: 12 FARLEY STREET METHUEN, MA 01844-9999 County: ESSEX AGREEMENT In return for your payment of the required premium, we provide the insurance described in this policy. LIABILITY INSURANCE COVERAGE LIMITS ANNUAL PREMIUM Each Occurrence Limit $ 1,000,000 /per occurrence Medical Payment Limit $ 5,000 /per person General Aggregate Limit (other than Products/Completed Work) $ 2,000,000 Aggregate Limit (Products/Completed Work) $ 2,000,000 Fire Legal Liability $ 50, 000 /per occurrence Personal and Advertising Injury $ 1,000,000 /per occurrence Property Damage Deductible $ 0 Included PROPERTY INSURANCE COVERAGE DEDUCTIBLE LIMIT AUTOMATIC REPLACEMENT ACV PROTECTIVE ANNUAL INCREASE % COST DEVICES PREMIUM Building Business Personal Property Loss of Income Business Personal Property - Off Premises FORMS AND ENDORSEMENTS SEE FORMS INVENTORY PAGE ANNUAL PREMIUM FORM NUMBER DESCRIPTION - ANNUAL $1,042.00 Name and Address $ 0.00 of Mortgagee: POLICY TOTAL .$1,042.00 NA our XuTtiorq&jAepresentawe Countersignature Date 08/15/12 AP -1 (11-90) (REV 1/94) INSURED COPY sq—* Is] 0 3 0 H W, rA W x. J W x 0 cc 0 mO N u +"_ 0 O LL y v+' N u +' CL N VI 0 d Z 0 Z m O O 'a O LL t O cr c E i U LL 0 W a z z J d t O 2' C LL W ul z J U J W O u O N mto LL 0 tc a in z N t O cr LL z CW a a 0 LJ. w CO O Z 41 yY m N v o Et Vl D J LLI _ R .O V : W •Q a CL cc °3 : z a)Q :C7 's c :z IE t/1 O � G ..�� 0o V L C r+ QJ E �• _ L IL Z H `m U Cl) ar L y W 0acn xZ LJJ O Q. y = DC w W J CLQ' s '5 CD to) m ~' L 0 ea 0.y tm t- O =12* Cc c = m Q O to V mcc d W = -0 O O Li y to OO .��. Z y B OE V CJ i dd O-0 d > U) -0 o C �)O �oCJ > E W CA U) W W 19 W H The Commonwealth of Massachusetts Department of Industrial Accidents Office o fInvestigations 600 Washington Street Boston, MA 02111 U www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: f\--f� tel\ C k -�> 1 City/State/Zip:-y3.tJ / /i¢� Phone #: 97 E 0 Are you an employer? Check the appropriate box: . ❑ I am a employer with 4. ❑ I am a general contractor and I em s full and/or part-time).* have hired the sub -contractors VAI-arn 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 ❑ 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.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other my applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. im an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: dicy # or Self -ins. Lid. #: Expiration Date: b Site Address: City/State/Zip: :tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Le 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. `o hereby certyiul e palpeoff ,O -pen >Aes of perju Zat tl1B information provided abOyC is trl[e find correct one #: % ,�:>S �"� 307 C9 g Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A Office a Cie �Pc+q f Consumer ���f U° ea/� 2 gMt arsS Mon OyEMENT'CpN$usi SS Regal, �4. oet x 1.73833 TRgCTpRn piratio N&B GE. n:1.1L1_12Q1.4 NERAL Co _ter, pBq TYpe: MC !,! - GING==-,,•.r:. _;. 12 FOLAS BRANCH�N ARLEy ST. METHUE N, MA 01844 4 _ • Undersecretary Mass"ichusett.s - Dcl)IIt of Public Imen Board of Buildim, Re,r S,iteh Construction Su ''ullitions and Stilndai-de pervisor License License: CS 66083 NICOLAS BRANCHINA .12 FARLEY ST METHUEN, MA 01844 C LZ �- C'un,missionrr Expiration: 8/21/2013 TO: 3761 TKQ r Contract Date Contract # 1/9/2013 298 . 'P.O. No. Terms Due Date _; : Rep Account # FOB Project 1/9/2013 Description Total Remove Christmas lighting and put aside. - 3,800.00 Tear up all shingles down to plywood and dispose of debri. Nail down all lose roof boards and replace upto 60sgft of damaged roof boards. Install all new ice and water shield on all roof and install aluminum drip edge. Install all new asphalt shingles. .Install Christmas lights again. e, e `�11;7Z%2�� Total �/ ;soo.00 ,- Win' Signature �G- �, This certifies that.. � ./ i'h/k �( ? ` I I C L40- hasermi e-2 t p ssion for gas installation . ....................... � . . in the buildings of . 1'n, l "t ......................... . at ....rj.?jY�j...� 1�.�!Cn p ! J..... , , , , North Andover, Mass. 1 . oFee .Lic. N�j... .... 1115Z4i GASINSPECTOR Check #� 8417 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ; G MA DATE'/jam PERMIT # JOBSITE ADDRESSNicbortnT 53S OWNER'S NAMEIn a2 LIDC GOWNER ADDRESS TEL£ FAX i TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL. EDUCATIONAL RESIDENTIAL . CLEARLY NEW:; RENOVATION: REPLACEMENT:,>—, PLANS SUBMITTED: YES N0 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 19 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _. DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER _ .. _ ...:... ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES G ' NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. C HECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR 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 com lance with atl Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , PLUMBER-GASFITTER NAME' MICHAEL H HOUSE LICENSE # 7173 SI NATUR MP + MGF + JP ; JGF LPGI < CORPORATION . + # 3377 C PARTNERSHIP # LLC # COMPANY NAME:` MERRIMACK VALLEY CORPORATION ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIP: 01844 TEL; 978-689-0224 FAX, 978-689-2206 CELL: 978-884-3427 EMAIL Ilittle@mvalleycorp.com or srutter@mvalleycorp.com j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www -mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Aa!±�rlMt Name (Business/orgmizadonMdividual) : 40' .710saaCIZAP: �t�©-EM11Phone#•Q79,Are on an emimner e �roprlate boa: y eni 1. I am an employer with 4.0 I am a general contractor I ype of project (Tegaired): and employees (full and/or part time).* have hired the subcontractors6.0 2. 0 I a sole proprietor or partner- New construction listed on the attached sheet. ip ship and have no employees 7. 0 Remodeling These sub-cont�m have working for me in any capacity. employees and have workers' [No workers' comp. insurance 8. f J Demolition required] comp. insurance. $3. 9. C Building t1 1 am a homeowner doin all work5' 0 We are a corporation and its officers have exercised theirm myself [No workers' comp, 10.0 Electricalg or additions ri reqs]t ght of exemption perm MGL 11. 0 Plumbininsurance g repairs or additions c.152, § 1(4), and we have no [no workers'comp. 12. U Roofemployees. insurance required.] 13ZerZ41e,0 .1-4 *Any aPPhcant that checks box #1 mast also Sq out the section bek►w sh , I % ��y �- tHomeowverswho submit this atifdavit lo Weir workers Comp; tion policy mformataou ;Contactors that check dkatiq �Y are doing 0111 work and then hire outside contractors must submit a new this box most attach an additional sheet showing the name of the sub -contractors and state af&lavk mdicath►g such. the sub -contractors have ees, theymust provide their workers' co whether or not those entities have employees, If number. I am an MWloyer that isProvidEng workers' comPensadon insurance or information. I my employees; Below is the Policy and job site Insurance Company Name:_ /1IJ.A�,�-moi. r./�, / . I - , Policy # or Self -ins. Lic. " Expiration Date: /3 Job Site Address: 3S�I/r��P��:c� �� ^ ` _ . / 4 - 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 152 can lead to the imposition of criminal up to $1,500.00 and/or one year imprisonment as well as civil Penalties of a fine $250.00 a day against violator. Be advised that a w of this Penalties 1n the form of a STOP WORK ORDER and a fine of DIA for coverage verification PY statement maybe forwarded to the Office of Investigations of the I do herby Print Official use only o1at the in 0 1-9 If "70itProvided above is true and correct AWP. �v �•t- Phone Do not write in this area to be completed by city or town of,�rcial City or Town: Permit/1lcense #• Issuing Authority (circle one): 1 -Board of Heath 2. Building department 3. City/To 6. Other wn Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact person: Phone #: May 07 12 02:27p Mike House 2079658719 p,1 '. v .. frf -F' V1:.. r-.: • Nye `:= ` . .:r £.� = VM- :: n�, CA x �z In Date. Z�19 .. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 ♦ �SACMUSC� 4 y� � f. This certifies that ..�. �` ��...!: l.. /............... ........ . has permission to perform plumbing in the buildings of9FL.!!+..................... . at... .'..!E. ....... ,North Andover, Mass. Fee d Lic. No.. .. . �......... . PLUMBING INSPEC 4OR Check # qc, V c7 7979 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: JA- r214-4- A lo /7, . MA. Date: Permit# V-1 7 —L -Building Location: j 3 ?� DA Owners Name: Type of Occupancy: Commercial Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: Alteration: Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ 5 Installing Cnompany Name: 1 L� Check One Only Certificate # Address: ly,) r ❑ Corporation 121 City/Town: State:. 4,Partnershtp Business Tel:. Fax: ❑ Firm/Company Name of Licensed Plumber: �,vau,V NUt UOVERAGE: i have a current-flability 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. A 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. Check One Only. Signature of Owner or Owners Agent Owner ❑ Agent ❑ 1 -ham y cqraty that allo 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 provislon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber 9 Si nature of L' ensed. Plumber � Cityfrown aster APPROVED OFFICE USE ONL Uourneyman License Number: 11. � z z Y O V nom. IX z Y} j H w Z IX LU QQ z 0 Q M Z D im U.Q a W 0 .Q w? W N a v a W 0 F=..= a 0� 3 v Z¢ °- 0 3 a Y Z= w w W 0 a a m a m N o m 0 a c u. 8= o Y� s � °�.X o O n� z to 0 SUB BSMT_ 5 Installing Cnompany Name: 1 L� Check One Only Certificate # Address: ly,) r ❑ Corporation 121 City/Town: State:. 4,Partnershtp Business Tel:. Fax: ❑ Firm/Company Name of Licensed Plumber: �,vau,V NUt UOVERAGE: i have a current-flability 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. A 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. Check One Only. Signature of Owner or Owners Agent Owner ❑ Agent ❑ 1 -ham y cqraty that allo 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 provislon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber 9 Si nature of L' ensed. Plumber � Cityfrown aster APPROVED OFFICE USE ONL Uourneyman License Number: 11. � JAN -16-2009 13:29 FROM:NORTH ANDOVER FIRE 9786869594 i k ?- Co y For. Fire Department TO:819786889542 P:1/2 FIRE ALARM MAINTENANCE & TEST REPORT PROPERTY - ----C-hickering Pro ertles ADDRESS ; 535 Chickering Road North Andover, IVDA MANUFACTURER MODELS NUMBER OF ZONES 12 Knox Box I key box YES r IO r" ZONES TESTED 12 REMOTE TROUBLE ZONES FAILED INDICATOR OPERATIONAL r YES Sensitivity TOTAL Cleaned Tested Tested Failed SYSTEM SMOKES 14 6 13 0 910 vac SMOKES 2 new 2 0 DUCT SMOKES BEAM SMOKES TOTAL # TESTED 4 FAILED Q RATE/RISE HEATS 13 12 4 RATE ANTICIPATED FIXED TEMP RESTORABLE 6 6 2 FIXED TEMP NOW RESTORABLE 72 TOTAL # TESTED # FAILED : ug . s HORN / LIGHTS HORN/STROBES INSIDE ---HORN$ MINI HORNS 1 STROBES STROBES HORN / LIGHTS HORN/STROBES OUTSIDE STROBES BEACONS 1 10 VAC LIGHT (Above Master Box) TOTAL TESTED # FAILED 15 1 0 3 3 .2 r NA JAN -16-2809 13:29 FROM:NDRTH ANDOVER FIRE 9786689594 TD:819786BB9542 TOTAL TESTED FIRE DOORS TESTED BED SHAKERS HVAC SHUTDOWN r-1 YES r No REMOTE ANNUN, ELEVATOR RECALL r- YES rNo FIRE DRILL SWITCH ANSUL SYSTEM F YES F No DATE iESTE p, no date LOAD TESTED D _V GES TESTED ON BATTE /ES p- YES NO r GOOD r ALL ZONES � NO 17 50%r NOTIFICATION DEVICES MARGINAL vo. YES ANNUNCIATOR FAILED MASTER BOX r YES f- ND r NA REPLACED YES 40 DIGITAL COMMUNICATOR �'" YES f` NO Nq YES i- NO MASTER BOX (Gamewell) w 1256 •. �" MASTER BOX (Electronic) MoswSox 9 TESTED TESTED SUPERVISEC DISCONNECT .j`v r YES YES 17 NO c (Of- Electronic Master Box) NO To Fire Dept r7- YES - NO Trouble SIGNAL TRANSMITTED TO FIRE HEADOUARTERSFACP i- YES f= NO DIGITAL DIALER I -YES rNO Acct# T- YES P.- NO DIGITAL DIALER TRANSMISSION' RECEIVED B— Y; TESTED' YES I"' NO ANNUNCIATOR SUPERVISION OK MASTER BOX SUPERVISION OK 7 YES I" NO f NA ZONE SUPERVISION OK YES NO �` NA HORN CIRCUITS SUPERVISION OK ,, YES r NO TROUBLE SIGNAL 8 LIGHTS SUPERVISION ,F YES r' NO OK A/C CIRCUIT BREAKER tr YES (7, NO A - IDENTIFIED r YES it NO B - LOCK IN PLACE T- YES f- NO ".. SPRINKLER SYSTEM INSTALLED IN BUILDING 1 ;- SPRINKLER SYSTEM CONNECTED TO FIRE ALARM SYSTEM YES NO YES NUMBER OF SPRINKLER ZONES )" NO ZONES CHECKED FOR OPERATION SPRINKLER TEST REPORT ATTACHED r YES " NO COMPANY RESPONSIBLE FOR TEST REPORT r- YES r- NO mooea .�•.. , w , a smo a etector a pull station, and a horn strobe -in the Iiquior store. Changed out twc na ed hea detectors and added a smoke detector in the convience store. Added a heat detec d a strobe in the bath room of the ua shop, changed a damaged heat and added a horn / stn In the basement. Added a smoke detector in the laundry_ Added three smoke detectors and a rn/strobe in the Kids Carosal. Added a smoke detector in the lock sho P. Added a smoke detec the hots frames op. Replaced a dams ed heat detector and tine voltage smoke detector ih U A. Added a line volt2ge smoke detector in unit B. TECH LI C# 599-D James Kukene COMPANY LIC 9 95 TEST CONDUCTED BY (TECHNICIAN) DATE ' 19/200 ---- PRICE P: 22 FORM U - LOT RELEASE FORK (INSTRUCTIONS: This form 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.' ****************Applican fills out this section***************** r APPLICANT: Phone Z./ P -LOCATION: Assessor's Map Number D Parcell, Subdivision Lot(s) -4treet St. Number . 7 ************************Official Use Only************************ i / RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments V/ i Inspector -Health Septic Inspector -Health Comments i Public Works - sewer/water connections - driveway permit vFire Department Date Approved Date Rejected Date Approved /d Date Rejected Date Approved Date Rejected Received by Building Inspector Date