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April 12, 2016
Michael Winston & Associates, LLC
Innovative Risk Specialists
POB 10721
Bedford, New Hampshire 03110
Tel: 603-494-2366 - Fax: 888-306-8106 - E-mail: michaelwinston@comcast.net
Building Commissioner/Building Inspector
Board of Selectman/Board of Health
1600 Osgood St. Suite 2043
North Andover, MA 01845
RE: Ben Osgood
Old Salem Village
10 Hepatica Drive
North Andover, MA 01845
Type of Loss: Frozen Pipes
Date of Loss: February 17, 2016
Policy: BP28014146
Claim number: BOP54815
Our File #: MW16-106 Location of Loss: Same
To whom it may concern:
The above captioned claim has been made involving damages or destruction of property which may exceed
$1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice
under Massachusetts General Laws, Chapter 139B is appropriate, please direct it to the attention of the
undersigned and include a reference to the captioned insured, location, policy number, date of loss, cause of
loss and claim or file number.
On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated
above via first class mail.
Sincerely,
Michael Winston
Adjuster
Date. .......
OZ
TOWN OF NORTH ANIDO"V
PERMIT FOR GAS INSTLMLATION
CHU
This certifies that 9. x .. .................
has permission for gas installation � .........
in the buildings of ...................................
at . . A. -'t %-
. ......... , North Andover, Mass.
Fee. .)c,) ..... Lic. No..�2,�:� ...
GASINSPECTOR x
Check # 2/- &
5765
Date .................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
L
This certifies that ................. -7
... v .... :t.,, ..........
has permission to perfonn ........ &5�W 725�ol'9
....................................... I ........................ ..
wiring in the building of... .............................................................................................
at ......... �4 ......... ��Iq 7-1r,9t
..... ........................................
... ............. . North Andover, Mass.
Fee ... ......... .... �7
..............
�heck# IF—qq V 0
13 I
n 0`0* 7
L,om.monwoJ4 o f Vamac4ueettd Official Use Only
Permit No.�`� z2epartmant ol��ire Jervica6
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [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 IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: M AnLur , - 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) 10
Owner or Tenant ",_ k;,,,,,,, Zhe:� Telephone No. 50?j-3.,9_ H(S6
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No 19 (Check Appropriate Box)
Purpose of Building 4 ,-Y\0 6 ire, k _, Utility Authorization No.
1 11
Existing Service \W Amps IALkoVolts Overhead ❑ Undgrd No. of Meters l
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 60 � �`�� e,M n kra \, �,r r
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 ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
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 El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of WaterKWNo.
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 Eq uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 0 0 (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 overage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:)
I cert, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: G LIC. NO.: ao (FOA
Licensee: [�r;r; �� Signature LIC. NO.:
(Ifapplicable, enter "exempt" the Jicekse number line.) Bus. Tel. No.: `t �' 7136
Address: °a`*O
\ �.,v,C►ye. Qom, HA- (It 23 5 Alt. Tel. No.: q7b' 7
*Per M.G.L. c. 147, s. 5t-61, security work requires Department of Public Safety "S" License: Lic. 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.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
G
MASS,,,30HUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING )�
(Print or Type)
Mass. Date 20 94 Permit # G j�
Building Location f%vM� f �Ap,✓ ,�fcphAjj�i4Bnw er's Name /moo y
Telephone *72/— (,o 7 3 , j j� Type of Occupancy
New Renovation Replacement Plans Submitted: Yes Nor]
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 Partnership
Business Telephone (800) 822-1300 Manager -Bob Olander X8055 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
INSURANCE COVERAGE: EnergyUSA Propane -,-Inc:- ..
has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes X❑ No ❑ .......
If you have checked ves, please indicate the type of coverage by checking the appropriate box.
liability insurance policy X❑ Other type of indemnity Bond
NNER'S INSURANCE WAIVER: 1 am aware that thd1Icensee does not have the insurance coverage required by
iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. ;
Check one:
Owner ❑ Agent ❑
nature of Owner or Owner's
I hereby certify that all of the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Code
and Chapter 142 of the General Laws.
wType of License:
By El.Plumber
Title `0 Gasfitter
CitylTown X Master
APPROVED (OFFICE USE ONLY) Journeyman
Signature of Licensed Plumber or Gasfitter
License Number 3707
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..-■■■■■■■■■■■■■■■■■■■■■■■■■■
..-■■■■■■■■■■■■■■■■■■■■■■■■■■
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 Partnership
Business Telephone (800) 822-1300 Manager -Bob Olander X8055 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
INSURANCE COVERAGE: EnergyUSA Propane -,-Inc:- ..
has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes X❑ No ❑ .......
If you have checked ves, please indicate the type of coverage by checking the appropriate box.
liability insurance policy X❑ Other type of indemnity Bond
NNER'S INSURANCE WAIVER: 1 am aware that thd1Icensee does not have the insurance coverage required by
iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. ;
Check one:
Owner ❑ Agent ❑
nature of Owner or Owner's
I hereby certify that all of the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Code
and Chapter 142 of the General Laws.
wType of License:
By El.Plumber
Title `0 Gasfitter
CitylTown X Master
APPROVED (OFFICE USE ONLY) Journeyman
Signature of Licensed Plumber or Gasfitter
License Number 3707
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Date.
"ORTH
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TOWN OF NORTH AN�D.O R
PERMIT FOR GAS INST LATION
This certifies that P. 1A ��):? ..................
has permission for gas installation ...................
in the; -buildings of ..............................
....... North Andover, Mass.
at 4 -
Fee. .32 Lic. No.. Y._?. .
rGA IN
Check #
5766
As
G
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Date /a ,� 20 Permit # 6'G
Building Location Go� y 1�eoh�Ti'c� Owner's Name 14G4 e-- Tn/G.
Telephone 1'71r —1,_ 5r_3 3 Type of Occupancy e,—
New 1:1 Renovation ❑ Replacement 1:1 Plans Submitted: Yes El NoO
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 ❑ Partnership
Business Telephone (800) 822-1300 Manager -Bob Olander X8055 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
ISURANCE COVERAGE: EnergyUSA Propane; -Inc.
is a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes XD No M ..... -
you have checked y2s, please indicate the type of coverage by checking the appropriate box.
liability insurance policy X❑ Other type of indemnity Bond
NNER'S INSURANCE WAIVER: 1 am aware that the,licensee does not have the insurance coverage required by
iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner El Agent El
of Owner or Owner's Agent
1 hereby certify that all of the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Code
and Chapter 142 of the General Laws. „
By
Title
City/Town
APPROVED (OFFICE USE ONLY)
Type of License:
Q.Plumber
_Fl Gasfitter
X Master
Journeyman
Signature of Licensed Plumber or Gasfitter
License Number 3707
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Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 ❑ Partnership
Business Telephone (800) 822-1300 Manager -Bob Olander X8055 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
ISURANCE COVERAGE: EnergyUSA Propane; -Inc.
is a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes XD No M ..... -
you have checked y2s, please indicate the type of coverage by checking the appropriate box.
liability insurance policy X❑ Other type of indemnity Bond
NNER'S INSURANCE WAIVER: 1 am aware that the,licensee does not have the insurance coverage required by
iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner El Agent El
of Owner or Owner's Agent
1 hereby certify that all of the details and information I have submitted (or entered) in above 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 provisions of the Massachusetts State Code
and Chapter 142 of the General Laws. „
By
Title
City/Town
APPROVED (OFFICE USE ONLY)
Type of License:
Q.Plumber
_Fl Gasfitter
X Master
Journeyman
Signature of Licensed Plumber or Gasfitter
License Number 3707
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Date...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....................... 5.,o%f 7—
.......... . I ..............................
has permission to perform ............. 41a ... A/ P0 S. C . ..............................
wiring in the building of ........... A-e..Y.6�..45 ..... . .........................
at ............. /4� ... !�T!.( ..... 0. a . .......... . North Andover, Mass.
Fee -.3— c. ov . Lic. No. 12:�3 174 ........... ... .. .. . . .... X " � A WV .........
tLECrRICAL INSPE - R
Check #
7085
Commonweaftn of Massacnuserrs v - -
De►,Je"�d'P# of F/%P Services Pe
Occupancy
J
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leaveblank
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 IN INK OR TYPE ALL �INFO ATION) Date: /2 - -4—_e
fj
City or Town of: &� ,� 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 A
Owner's Address
Fri
170
TeItphne No. 1/g/ yJ
Is this permit in conjunction with a building permit?
U Yes ❑ No
❑
(Check Appropr4nte Box)
Pur ose of Building
P g
` tility Authorization No. / 7G — :Z.3 Ci Z
Existing Service nps / olts
A
Ove ead ❑
Undgrd
❑ Na. of Meters
New Service 200 Amps v Volts
Overhead ❑
Undgrd
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: A4-- vv,r --
rmmnletion of the following table may be waived by the Inspector of kVires.
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: /2 y" --G G 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 pen -nit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, raider the pains and penalties of perjury, that the information on this application is ti -Ilea17 complete.
FIRM NAME: Q E� / cv%� LIC. NO.: Jr%3
Licensee:/ / Signature A LIC. NO.: 9i 33
(Ifapplicable, ter "exempt" in the licensenumber line.) Bus."Ml':1vo.:R'7—Zf��
Address: Alt. Tel. No.:
*Security System Contractor License required for this work; i applicable, 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 agent.
I'% .... / A -(
kjwne„�gent I Yt✓1tIV11'1 FEE: m 0 ✓
"j
Signature Telephone No.
No. of Total
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above o In-
Swimming Pool rnd. grnd.
No. ot Emergency Lighting
BatterY Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection andInitiating
No. of Switches
No. of Gas Burners
Devices
No. of Ranges
No. of Air Cond. Tons Tot
No. of Alerting Devices
Heat Pump
Number
Tons
KW
....
No. of Self -Contained
No. of Waste Dis osers
P
Totals:
..
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑Municipal El Other
Connection
Dryers
No. of Dr y
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
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: /2 y" --G G 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 pen -nit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, raider the pains and penalties of perjury, that the information on this application is ti -Ilea17 complete.
FIRM NAME: Q E� / cv%� LIC. NO.: Jr%3
Licensee:/ / Signature A LIC. NO.: 9i 33
(Ifapplicable, ter "exempt" in the licensenumber line.) Bus."Ml':1vo.:R'7—Zf��
Address: Alt. Tel. No.:
*Security System Contractor License required for this work; i applicable, 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 agent.
I'% .... / A -(
kjwne„�gent I Yt✓1tIV11'1 FEE: m 0 ✓
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Signature Telephone No.
TOWN OF ANDOVER
ELECTRICAL PERMIT FEES
(Effective March 12, 2003)
g,
URK
�rRM� 1"EI�xS
RFSWN� k,
NO SE CABLE ON
OUTSIDE OF BUILDING
c-.
n
Air Conditioners: $40.00 each
Alarm Systems Security: (for fire
systems see smoke/heat detectors)
Residential: $40.00
Commercial: up to 10 Devices
$60.00 additional devices over 10-
$1.00 each
Carnival Equipment: $50.00 each
Ceiling Fans: $1.00 each
Commercial New Construction or
Alterations:
$100.00 per 1,000 Sq. Ft. of
Construction Space
Commercial Service Change/
Repair:
Mast have Utility Authorization Number
$100 (first 100 amperes or fraction, one
meter)
a) each additional 100 amperes
capacity or fraction. $30.00
b) each additional meter $25.00
Commercial Temporary Service:
$100.00
ill:ust have Utility Authorization Number
Commercial Repair and/or
Maintenance Permit: (Blanket
Permit) up to 2 Electricians $150.00
per pair of Electricians over 2 $50.
Data/Telecommunication:
Residential: $1.00 per port
Commercial: $30.00 up to 10
devices over 10 - $1.00 each
Dishwashers & Disposals:
$5.00 Each
Dryers: $15.00 Each
Emergency Lighting (Battery Units)
$ 1.00 each unit
Feeders or Sub -feeders:
each 100 amp capacity of fraction
thereof
Residential: $5.00 each c
Commercial: $15.00 each
Gas/Oil Burners:
Residential: $20.00 each
Commercial $20.00 each
It',
r
ueuerdwrs rtesluenTlat &
Commercial:
a) including photovoltaic &
generating Equip Per KVA $1.00
b) un -interruptible power systems,
per KVA $1.00
N c) batteries over 100 amp. hours, per
cell $1.00
Heat Devices: $1.00 each
Heat Pumps: $40.00 each
Hydro -Massage Bathtubs/ Hot
Tubs: $20.00 each
Lighting Fixtures $1.00 each
Lighting Outlets: $1.00 each
Major Appliances: (not listed)
$20 each
Motors: (per hp or fractional part
thereof) $2.00
Oil /Gas Burners:
Residential $20.00 each
Commercial $20.00 each
1 Office Furnishings: per circuit $10
(Relocatable Partitions/Cubicles)
Outlets & Fixture: $1.00 each
yens Built in/Counter Top Units:
$10.00 each
Panel Change/Circuit Breaker:
Residential: $20.00
Commercial: $25.00
Phone Jacks: See
data/telecommunications
Ranges $15.00 each
Receptacle Outlets: $1.00 each
Recessed Fixtures: $1.00 each
Re -inspection Fee: $25.00
Repair to Service Residential:
$20.00
Residential New Construction
(Dwelling): $220.00
(with service up to 200 amps)
Must have Utility Authorization Number
for services over 200 amps see below
a) for each 100 amps capacity or
fraction add $20.00
b) each additional meter $10.00
c) each additional panel/sub panel
$25.00
Residential Additions/Alterations:
$220.00 maximum
Residential Service Change or
Underground Service:
$40.00
Must have Utility Authorization Number
a) one meter, up to 100 amp capacity
$40.00
b) each additional 100 amp capacity
or fraction $20.00
c) eacn aactitionai_meter ..siu.UU
Sewer Ejection Pump: $25.00
Signs: $25.00 each ballast
Smoke & Heat Detectors &
Initiating Devices:
Residential: $1.00 each
Commercial: $60.00 up to 10
devices over 10 - $1.00 each
Space Heaters:
area heating $1.00 each
Sub -Panel: $25.00
Swimming Pools:
Residential:
Above Ground: $25.00
Inground: $50.00
Commercial Pool: $100.00
Switches: $1.00 each
Temporary Service:
kfust have Utility Authorization Number
Residential $25.00
Commercial $100.00
Transformers:
a) capacitors, Per KVA $1.00
b) ducts, conduit & conductors
(Associated w/ Padmount Transformers) $25
c) each manhole $10.00
d) each handhold $5.00
e) per KVA $1.00
f) primary feeders, $25.00 each (over
600 volts, non-utility owned)
g) vaults and equip. $25.00 each
Washers: $15.00 each
Waste Disposals: $5.00 each
Water Heaters: $30.00 each
*For Multi-FamilIT
I-iarge Commercial Project
see Wirilig Inspector for
p1will g:
.Paul Kennedy (37£1) 623-8306
(Office flours A ani to 1.0 am)
k
*Inspection Schedule:
1 ROUGH
1 FINAL
I TRENCH (if applicable) "N
a
ADDITIONAL
INSPECTIONS *$25.00 (if
applicable)
(revised 07/05)
"I
Date ........ /Z 7:� �6. '. �P. (P
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .................... .....................
.!7,-Ao /P
has permission to perform ...............................................................................
wiring in the building of ............. .................
rth 6in
at.... (1,ff ............. ............ . No dover, Mass.
Fee.r .... Lic. No.
9 '? z
Check #
7055
11
.4
J
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
'�
Permit No.
Occupancy and Fee Checked
[Rev. 9/05] 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 IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: /�/-e��vv �� m To the Inspector of Wires:
By this application the undersigned gives notice of his or hevintention to perform the electrical wJq k5gribe below.
Location (Street &Number) /�e ®A /-1 1- .-0- OV -.el y
Owner or Tenant , t f/ TelepllogA&A�f -
Owner's Address
Is this permit in conjunction with a bui mg permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building y.. .✓i e- ; f Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps /,74/11yvVolts Overhead ❑ Undgrd fjj�No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Cmmnletinn nftho tnUn- ina f.,h10 w , Ap . -;--4 1— .1.- 1a .. r u7.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ n- ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detectiin an
Initiating Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pumpumber
Totals:
7
Tons
1
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. o ea KW
Heaters
o. o No. o
signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Ielecommunicationsiring:
No. of Devices or Eq uivalent
OTHER:
,(ttach additional detail ifdesired, or as required by the Inspector oJ'17ires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start:-//-// -O clo 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:)
certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: ,,., / j 'LIC.
Licensee:�G `//' Signature LIC. NO.: 3
(!J applicahle, e er "exenTpt' in the license number line.) Bus- T1 eKNo.•i6�7 - Z/G0
Address: a 5��. Alt. Tel. No.:
*Security System Contractor License required for this work; i Kapplicable, 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 agent.
Owner/Agent—
Signature Telephone No. PERMIT FEE: $