Loading...
HomeMy WebLinkAboutBuilding Permit #815 - 7 COPLEY CIRCLE 6/2/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0:J/r Date Issued: IMPORTANT: A Date Received must complete all items on this rint PROPERTY OWNER �G�C h U /� n/nJ Print MAP NO: 0—PARCELS ZONING DISTRICT: Historic District yesano Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial "epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well: ❑ Floodplain ❑ Wetlands 0 Watershed District 0 Water/Sewer DESUF-W I WN UP w UK& I U tit; YLtcx UtuVMJJ. r/174 t --47C ova ✓�a�`�� Identification Please Type or Print Clearly) OWNER: Name: C�cd.C. � 4 v ,"PVL/ Phone: Address: CONTRACTOR Name: Address: �, /C-!�) Supervisor's Construction License: N ,A % % 6 5'0 Exp. Date: Home Improvement License: YQ 57 q Exp. Date: ARCHITECT/ENGINEER Phone: Phone: 6 NIX) 9� % ?/3h Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �d FEE: $ / 3 / Check No.: Z Receipt No.: Q q a, f - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contactor Location Sff- No. f Date r �� TOWN OF NORTH ANDOVER A ;e Certificate of Occupancy $ ' I A,�„Building/Frame Permit Fee $ . 12, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Q% 0 7, 2 + Building Inspector Date.........�:7..... J.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING k!s..I�v nThis certifies that .....!.,, JCr.. k. !........................ has permission to perform ..........tn S ''� ! !is✓ Jr wiring in the building of5,"1:.-�,�V/.9Z .............................................................................. at ................Cd -I. (ii �' ......... ............. . ...................... , North Andover, Mass. Fee.... �....r. Lic. No. 3.�1 . .Z- QI.. .......... . :'%.'?'.tl�:�.':!:l ........... ELECfRICALINSPECTOR�y Check # � >(?� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board -Decision: Conservation Decision: Comments Commen Water & Sewer Connection/Signature Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main 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 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 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008mi 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 o 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) ❑ 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 E, Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report o 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 submitted with the building application Doc: Doc.Building Permit Revised 2008mi U) m m m N v m _v, y CD d C `C 'O O a Z y CD Cl C , r c � � c d= CO)Co O 0 v c� CD O Q CD CD O CD CD c CD 9O y CO O CD F v c 1 CD y, CR SF O CD O CD 0 C 0 O 0 CD O co O CD d Cfl 6 m Cfl c 0 H C CL 0 H W C = O d dca cr �. COm ®0 m ti O .► C �. O d '� Di . H = ,. CD m dim O ? m O �p O C09 �. ...► n d y a =' C2 dc =r Z" CD CD y o.� m y d: DJ CO) CL w �CD CD H COL Ca m � CD Cfl � CD CD oma: moo: N rA moo: CD C* m o a� CD y I CD CD CD d Di O 'O d � C J C- CO2 C7 T T Fn m C� As _ �p (� rt w W pGq z z n ;tC/)al p G ' 3 O . � H ►-3 � 'ti '� 0 tai O z H 0 Information and Instruefi®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an em ployee is defined as "..,every person in the service of another udder any contract of hire, express or implied, oral or written." An e1uployer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe 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 badeemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a Iicense 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 PIease fill out the workers' compensation*affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) 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 cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confinnation of insurance coverage. AIso 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 ifyou 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" the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/lieensenumber 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 (if necessary) and under "Job Site Address" the applicant should write "all locatiin (city or town); ' A copy of the affidavit that has been officially stamped or marked by the city or town may bonse provided to the applicant as proofthat 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 pen -nit not related to any business or commercial venture (i.e. a dog license or permit to bum 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, Commonvrealth of Massachusetts Dgpartmeut of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext406 ox 1-977 WSSAFE Revised 5-26-05 Fax # 617-727 g74g wuw mass.gov#dia AY ' The Commonwealth of 1Mlassachusefts Department of Industrial Accidents EE ; Office of Investigations 600 Washington Street '+I V Boston MA 02111 ,s v wwminass gov/dia Workers' Compensation lnsurance A� ridavit: Builders/Contractor•s/FIectricians/Piumb ers pplicant Information . Please Printi Lepribli Name (Business/Organization/Individual): Address:_ % Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. 0 New construction City/Stale/Zip: s�d2 �' Phone#:_ 6 d; These sub -contractors have Are you an employer? Check the appropriate box: 1. I am a employer with �^ 4. ❑ I am a general contractor and 1 Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. 0 New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # 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. ❑ Building addition required.] officers have exercised their 10. El Electrical repairs or additions 3. ❑ 1 wn a homeowner doing all work right of exemption per MGL . 11.[I Plumbing repairs or additions inyself. [No workers' comp, c.1-52, § 1(4), and we have no 12.0 Roof repairs " insurance required.] i employees. [No workers' 13.❑ Other comp. insurance required.] Thny appi scant mat enecxs oox rt i must also .till out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and Thep 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 acid their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: lAYI Policy # or Self -ins. Lie. #: (;/ G �� /ll _•^� t 12 Expiration Date: // It i h f Job Site Address: �O/JIPu C, l 2C/(� /V, /y�y�.. 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 Iead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penaltles ofpetyury that tiie information provided above is true and carreck Si-anature: Date• Phone #: 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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: -p m w m m 0 0 0 D —m U) m -n M W W 'p ° 00 c ° * = a C x G (D 0O Q Q O O O Q �' (D (n lD (D <D �t 4,�• N _ X Q O T O Z F G OV/ x mN v CD rT 2 O awvCD o �-0 (D w C') E c p OOO O Op O Q v cr N @Cv .. O O '� O , co co C O (0 _ n 15 CA N O x 'O O a U) Q c a G — O O CD C O �.iU `O' W C(i N < a •.t n O = n Q 70 v O (0 � Cl) r c v o r (D CL ? O t CD �= s p O a O Q (TQCD O a N• �• �i CD (D ;:w 0) CD CD cr n 0 `C (D V v F �. c� '.3 .-► -. G v Y Sv C, v CD r . co 'G A cr cr U) r 6` � r �• 'ZJ (OD CL Cp c�■ A6k, CD c� �v. O +��. W? CSL) p•r —vo 0 CD O v r �j VM VC' g a a c R V a o iD Z r o c o �' v N j (D O -+ 0 U g o V W O CJ1 O rt z OCLm O O O O' i < (D = i j \ -Os 00 02 c„n O CD O 0) O Can O I o a a T+ao m >m Xr~ c) C-) n m m m 0w -p CL m D ° w ° w= w 0-1 a0Q a v 3 33 �aa _ c s 6 N N CD CDn n Cr 3 a rCD m N V) CD fD � O O (D cfl CD # Z _y (IC r 3 �• CD N CD L cr CD O X - 0 m ==° O > ° 0 0 CD CD -' a O n -+ 0 w ffl 0 0 O C ° O CD W� � CD CD CL O ca O0) m OO w ' CD CO O 0N l vin a :3c� CD " o :3 CD ° (0 a_. r O p? r rZS Q CD w O0 0 D w O S CO Q. s o �� w w "* 053 . p<j CD CD a 7_ w cn r 5 r+ cD CD w r, 2 w n 0° N = Cl N Q r c 1 3 CD l< cn a° o p cwn CD �' �• ryo c�D �' Cz U) =P � CD 6 mto g o m c f N n U) C ° � - N y O I m w is °_' 3 F) �C I 9�� ,f�� cao m ° c ° I w CL c 0 Q 3 cn cn z ww n ° n CD 3 � a c o C/) n cn O CD �3 a O w O P/ri ti rro fJC cn 7 E+JO L1 _ CD CD �� scra•f ��^ � � C y� y C: ? r a s n k7 Z rFp�.�. Q- • i r r C N (D v n n -r a v 0 = 0 a w 0 tcDii cD cn o_ z g 0 1 m y -% Cl) V V Cat > 0 Ut O = 0CL Ct O O CD O 0 w k CD � CD = + ' ate_? O co y a � � w =v 0 0 (D cn cn o 0 0 ! 0 0 0 0 0 a M rn cn 0 N O 4 O �) * �* O C O yv Ntn CJIONCOO (Da QO O cn 0 W M _ (D v O �T a w © O n a) ? 0 -0 -0 to (n to to O CDP.O. g _� F QDQO z _I C a M rn cn 0 N O 4 O �) * �* G) inM :r;Z, � cri -' Ntn CJIONCOO (Da QO O cn 0 W M _ (D v Z�N = �T a w © O N O a) ? 0 -0 -0 to (n to to 0 �o _� F QDQO z _I C N Q v o�mn�����,� m �7 cin CCL DD Rt o mo :U :� C cn (3 - w w o C7 0. D tD a� C) CD > Y O C7 O o v (D x x x o- o o ° - m _ m ni v co � (0 co a OZ m D to (D ,v Qcr CR — m cr o CD ? fA (p (p (D v + _s. cnw ::rto o 7 = x r+ O --4 C m X- -�, o O + Y (D O CD N O —,..o < C � _ (D CD tD 3 CD ro W_ m fD-�<-,- (0� O" C o � Q O x N= * O Q (D O O CD CO cr N w 3 art Q m m Q Q "' • r�-r G r -t Q =�� mvo-* < 0- • to to Q is m 5�=c'oo < 0 _ Z to O is n N C N � O 7 Q * CD CT ( ,— 0 Q x 0 D Z o 00 N O m (p Q a M rn cn 0 N O 4 O � rr cD 5. 0, � cri n m C) CJt C ■ tl v Z�N = �T a w N 0 N N O m m T 0 w T rr cD 5. 0, N n m X <D C ■ tl v Z�N = �T a w O O o (D �rnc�ac�D� m N O 0 M 0 @ 0 �o _� F QDQO z MC p N Q C to W 0 _.4� o �7 s n � CD Q..0 2) CD :� C < (D O CD ' . n N .: .: n cD N n m C ■ tl v 3 oCD �T a w N O O B n .: .: l!- C ■ tl v a w N O CD n N z P tCP .. w O , CJ _.4� o Cli v a w N O CD n N z .. w M _.4� o s n � Q..0 2) CD < (D O CD ' . n N a� C) CD 0 0o y Ul w_ rQ O O � Massachusetts Home Improvement Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should fust obtain a copy of "a Massachusetts consumer guide to home improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757. Homeowner Information Contractor Information Name Nkalter R Paula Schumann 7 Copley Circle Street Address (do not use a Post Office Box address) City/Town Stat NORTH ANDOVER VIA Daytime Phone Evening Phone 978-688-5829 Company Name PROFESS ION Al- BL IL.DIN(j SERVICE -S Contractor/ Salesperson/ Owner Name Peter Ciaralei 9 OLDFWOODS RD Zip Code �usiness Address (must include a street address) 01845 SAI_Etil ti 1-4 03079 Cityfrown State Zip Code Mailing Address (It different from above) Business Phone Federal Employer ID or S.S. Number 603-898-297'i 20-5303576 Law requires that most home Home Improvemem Contractor Expiration Date y� Improvemem contractors have a valid reg. member ReOsuatkm ra ober The Contractor agrees to do the followi g work for the Homeown r: (Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, uI additional sheets if necessary.) SEE ATTACHED RETAIL I — Required Permits -The following building permits are required Proposed Start and Completion Schedule - The following and will be secured by the contractor as the homeowner's agent, schedule will be adhered to unless circumstances beyond Owners who secure their own permits will be the contractors control arise excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work, famish the material and labor specified above for the total sum of $10,955.12 Payments will be made according to the following schedule: $_3651.70 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $J$3651.71_ by _j0 /�! // or upon completion of ROUGH INSPCTION SIGN -OFF f 3651.71 % by / / or upon completion of —SIGN -OFF OF BUILDING PERMIT BY TOWN OFFICIALS $ upon completion of the contract (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following materiaUcquipment must be special $ to be paid for ordered before the contracted work begins in order $ to be paid for to meet the completion schedule.(**) NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty - Is an express warranty bane provided by the contractor? No Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this aareement. Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. * Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. * Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be req'u;5d to submit to such arbitration as provided In MassachuZonigniature s, chapter 142A. Homeowner's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law," contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Pack Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or 1-(888) 2833757 contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF TBERE ARE ANY BLANK SPACES!!! ,Two identical copies of the contrfct mdt be completed and signed. One copZuld hehmeowner. The other copy should be kept by thHomeowner's Signature r's Signature 6 -�z 6 Date Date N Commonwealth of Massachusetts Official use only Department of Fire Services Permit Na 7 1 d� WIN Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE 4 LL I7VFORMATIOl9 Date: 4 Z 2 l GLI City or Town of: Veo 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) Owner or Tenant PA e,t 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: (Z U!21 K_ . %)1 n ( SGL LI t [LLQ 60 1 G Xt q Su.y�,l2c m, dcu LICK-, Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ElIn- ❑ rod. rnte o.d. Bato Emergency Lighting Units No. of Receptacle Outlets $ No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of No. InDetection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number I Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal 11 Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FHtM NAME: LIC. NO.: Licensee: F LOO int COUQ611 Signature_S�� LIC. NO.: 396a? (If applicable, enter "exempt,, 1.!h the license number line.) S D ca Bus. Tel. No.• Z Address: did Alt. Tel. No.: MJ 06/ *Security System Contractor License required for this work; iflapplicable, enter the license number here: 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $