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HomeMy WebLinkAboutMiscellaneous - 10 ROYAL CREST DRIVE 4/30/2018�� a I Ir bb Date .... ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .................................................................. f . ....... has pennission to perfonn...:.�1�7.CAYZc*n I.> '2 L—)`2 .................................................................................... wiring in the building Of ....... V -r% 0 0 0 - . ......... ................................................. at ... JQ ........ hA las ............................................ . . ortn6dover,,mv Lic. No. u ........ .. .... .............. ........ Fee .......................... ................ . .............. ... .... ......... -71 k ELECTRICAL INSPECTOR 'Check # 1309-9 Official Use Only Commonwealth ®f Mass Uset y a Department of Fire Services Permit No. I>z�i Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (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 INIMK OR TYPE ALL MFORMATIOA9 Date: D e - C A, 14 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 Location (Street & Number) 9 work described below. 10.. Owner or Tenant e4M 1 C iyc)r }{ 4,4 ry OGS, e C U=(' . Tell ne No. Owner's Address 8 U t1&1;1U_ Is this permit in conjunction with a building permit? Yes ❑ No LTJ (Check Appropriate ]Box) Purpose of Building Utility Authorization No. - Existing Service New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed EIectrical Work: �L� Lo �Z c�,�dCa� ( C on n-ee✓.=t ori' 5 it„l �_��rt( S r-r,o s I c A r S 0--n at C it b u+ + Completion ofthe %llowin-e table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaire Swimming Pool Above ❑ In- Elo. rnd. rnd. 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 Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No.. of Dryers Heating Appliances KW SeCNo o De iIc s or Equivalent No. of Water KW No. of No. of Data Wiring: Beaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: • Attach additional detail if desired, or as required by the Inspector of Wires. • Estimated Value of Electrical Work: r G 0 (When required by municipal policy.) Work to Start: � ZA za t 1Lt Inspec ions 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: 1NSURA-NNE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: '�) 4 iU Licensee: 'J)g,1d P ViLsa&) SignatureQ&M,,-e7k P V1 (If applicable enter "exempt" in the license number line.) Address: 10 D P IC SS+LX)o-.l,k r vA. N A Oa45 1 LIC. NO.: Alb i 1 LIC. NO.: 3 1 Qj �6 C Bus. Tel. No.: Alt. Tel. No.: 50 -G *Per M.G.L c. 147, s. 57-61, 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 FPP,?mTFEE.- $. Signature Telephone No. The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www:mass.gov1dia riciansfflumbers Workers' Compensation Insurance Affidavit: Builders/Contractors/E1Please Print Le� Name (Business/OrganizationlTndividual): �)A1u\ CL 1 Address: Cato � fir, � City/State/Zip: l(A1c� �� Phone #: Are you an employer? Check the appropriate box: �4. E] I am a general contractor and I if am a employer with 1rs . ❑ employees (full and/or part-time)•* have hired the sub -contract 3 listed on the attached sheet. 2. El am a sole proprietor or partner- These sub -contractors have ship and'haveno employees working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL c 152, §1(4), and we have no myself. [No workers comp. employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction f 7. [1 Remodeling 8. [] Demolition 9. [] Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing. repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box91 must also fill out the section below showing their workers' compensation policy information. �1Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that cheek 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 Name: A, 1, i i i Policy # or Self -ins. Lic. #: �- � s �? a� Expiration Date: l CZo e�I G ! 4 S Job Site Address' 5 6�. City/State/tip: � p Ocz c � 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 DTA for insurance coverage verification. r I do herebScert fy under flee pains and penalties of perjury that the information provided above is True and correct. 1� 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. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone iQ -COMMONWEALTH OF'O c,,5 � C30 CERTIFICATE OF LIABILITY INSURANCE 1 8/26/14 EXTEND OR ALTER THE COVERAGE AFFORDEDERS THEBY POLICIES [ATE DOE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. T ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, t JV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU ,RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ohc les must be endorsed. If SUBROGATION IS WANED, subject to PORTANT: If the certificate holder is an ADDITIONAL INSURED, the p Yf ) Tie terms and conditions is the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to e j certificate holder in lieu of such endorsement(s). CONTACT LESLIE HANN ON FAX (978) 667-0587 NAME: PRODUCER PHONE .(978% 667-6150 AI No: James O'Connell Insurance Agen EMAIL JIMINS@OCONNELLINS.COM ADDRESS: NAIC # 572 Boston Rd INSURE S i AFFORDING COVERAGE Unit 7 INSURER A: Merchants Billerica, MA 01821 „oFR R - A. I . M. Insurance INSURED I NSU RER C : DANIEL, P VITALE ELECTRIC INSURER D 190 DALE ST MA 02451 INSURER E: WALTHAM � INSURER F REVISION NUMBER: COVERAGES IOD CERTIFICATE NUMBER: M OR CONDITION OF ANY CONTRACT OR OTHER EpOHEREEN IS SUB ECT TO ALLNT WIT H RESPECT O THE TERMS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCER STED BELOW HAVE BEEN ISSUED CT THE INSURED NAMED ABOVE FOR THE POLICY PER INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE IN AFFORDED BY T ou OLEFFES oucY EXP LIMITS EXCLUSIONS AND CONDITIONS OF SUCH aoDLIL sub LIMITS SHOWN MAY HAVE BEEN REDUCED B� PAID DD/CLAIMS. IL R POLICY NUMBER .TYPEOFINSURANCE N R WVD BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 1 000 .00 DAMAGE TO RENTED Ce $ 500.00 A GENERAL LIABILITY 15 O O A one person) $ — X COMMERCIAL GENERAL LIABILITY MED EXP ( nY---- $ 1 O00 OC OCCUR PERSONAL& ADV INJURY CLAIMS -MADE GENERAL AGGREGATE $ 2 0 0( Ono OO( PRODUCTS-COMPIOPAGG $ 2 OOO OO( GEN'LAGGREGATE LIMIT APPLIES PER COMBINED SINGLE LIMIT $ PRO- LOC X POLICY Ea accident BODILY INJURY (Per person) AUTOMOBILE LIABILITY BODILY INJURY (Per accident) $ ANYAUTOPROPERTYDAMAGE ALLOWNED SCHEDULED $ Per accident AUTOS AUTOS NON -OWNED $ HIRED AUTOS _ AUTOS EACH OCCURRENCE $ UMBRELLALIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS -MADE $ WC STATU- OTH- DED RETENTION $ WCC5006538012009 10/11/13 10/11/14 X $ 100 , 0( WORKERS COMPENSATION E.L. EACH ACCIDENT 0 ( B AND EMPLOYERS' LIABILITY YIN100 —I N I A E.L. DISEASE -EA EMPLOYEE $ , ANYPROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? _j E.L. DISEASE -POLICY LIMIT $ 500 ,0 (Mandatory in NH) If ves, describe under-- A T nn s heInW DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Attach ACORD 101, Additional Rerredcs Schedule, if more space is requred) cTcr-TRTCAL WORK TIFICA' TOWN OF NORTH ANDOVER MA 120 MAIN ST NORTH ANDOVER, MA 01845 LESLIE HANNON © 1988-2010 A ' The ACORD name and logo a Ire registered marks of ACORD E-M ACORD 25 (2010105) Fax: Phone: r. AN CELLATIO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF THE EXPIRATION DATE THE POLCYEOF, NOTICPROVISONSE WILL BE DELIVERED AUTHORIZED REPRESENTATIVE CORPORATION. All rights reg NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street North Andover Tel: 978-688-9545 Fax: 978688-9542 BUSEVESS FORM FOR TOWN CLERK DATL: �5' oZ l7J NAME: �S �:�� (51v ADDRESS; ZON GDISTRIOT: � TYPE OFBUSINESS.: D/iylG cif/ BUIl,DINGLAYOUT PROVIDED: YES NO XV- A LAd3J E PAR14.1MG SPAM:_ ZONING BYLAW USAGE: YES NO INSPECTOR. SIGNATUPIE BUSINESS FORM FORTOWN CLERK ``-" 2.40 Home Occupation (1989/32) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use. of the building- for living purposes. Home occupations shall `include, 'but riot Ifinited to the following uses; personal services such as f unished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business, or the manufacturing of goods, A vhich impacts ilio residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi -family district for a home occupation, the following conditions shall apply: a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the of ier of the home occupation and residing in said divel ung, b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings, - d. Not more than twenty-five (25) percent of the existing gross floor area of ;the dwelling unit. so used, not to exceed one thousand (1000) square feel, is devoted to such use. In connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; C. There will be no display of goods or wares visible from the street; f. The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any resid use within the neighborhood; g. Any such building shall ' lade features of design. not cust6mary in buildings for residential use. $ignaiure17 Date Mrd North Andover MIMAP May 27, 2014 \� R �,� Yap t° • ��� �� i' x ,� i` V ill �, r-• ��� - ycPa ti y9 Tj l NJ AndoverNick �. 7 36y c D @ {, Wex — Rail Line '.-Wetlands Zoning Interstates C Exempt Lands Otine _ 13 Busine s 1 District s 2 11 aMcl Horimntal Datum: MA Stateplane Coordinate System, Datum NAD83, — SR D Busine O Busine Roads =Genera 1. rEasements OPlanne Ylfl. Corrido OMVPC Boundary 0 Corrido OMunicipal Boundary aCorrido Ind usl6 Zoning Overlay 0Industri s 3 District s 4 District �Qlit�`- Business District em W Commercial Dev ? r,�yc sea ® Development Dist " Development Dist Development Dist iL 4' 11 District 12 District'BAdult Meters Data Sources: The data for this map was produced by Mernmack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY Entertainment Cf Industri Overlay District 0Industri ODownic i z � } 13 District rt s I S District OF ASSUME THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Di OWaterProleclion Reside E3Watoric Protection ce 1 District", a THIS INFORMATION CReside O Parcels - 0 Raslde ce 2 Distract ce 3 District - 0 Hydrographic Features de -- Streams 1" = 766 ft ^ de ce 4 Distract ce5 District iii de e e ce 6 District esidential District 7 62 2 Date. . f /-� /-. �/ .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... 71f has permission, for gas installation in the buildings of .... n �m . !� ftcs\ .................... at A Q 44 X17 Oil - North Andover, Mass. Fee.;kOV�9. Lic. No.. GASINSPECTOR Check# �K34Y -C\- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING u,p City/Town: ii%1411,WU -,MA. Date: ZLf // Permit# Building Location: /0 4)$1,4L ( /WsQ'/ AV-- '�� Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: © Plans Submitted: Yes ❑ No FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes JR No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 9? 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 Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent By checking this box ❑; 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 ofthe General Laws. Type of License: �; By ❑ Plumber Title El Gas Fitter El Master Signature of Licensed Plum er/Gas Fitter City/Town ❑Journeyman License Number:��loU 7 APPROVED (OFFICE USE ONLY) ❑ LP Installer rn LLI N ~N Q 0: N L) W m 2 LLJ 0 WO J V CO) H U) 0 O Z O Z Nw 0 F- 0H= O Ow lW Q — w w w LLJ W O W LLI W X ~ > U W w} Q Z "I J W F- Z ~ O .� = Z J (7 LL N= U) Z W w W W z v a a 0 Q Q z m w O z O 0 W�>>> z O LL 0= a. SUB BSMT. BASEMENT 15T FLOOR 2 Nu FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: /;11IG4e V � &7 (r��atfln6ecIAL /�cycE,e - Vs. Check One Only Certificate # ❑ Corporation Address: 49GD17*41q XT City/Town: State: ❑ Partnership Business'Tel: 7J-1 07V `/yam% Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: ' i jw� / c.�5y INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes JR No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 9? 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 Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent By checking this box ❑; 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 ofthe General Laws. Type of License: �; By ❑ Plumber Title El Gas Fitter El Master Signature of Licensed Plum er/Gas Fitter City/Town ❑Journeyman License Number:��loU 7 APPROVED (OFFICE USE ONLY) ❑ LP Installer JEW BUSINESS -FFECTIVE DATE 12/23/2010 10�Peerless ., Insurance Mcmbcr of Libwy Mutual Group Aicy Number: GL 5432321Prior Policy: Billing Type: DIRECT BILL Coverage Is Provided In PEERLESS INSURANCE COMPANY - A STOCK COMPANY Named Insured and Mailing Address: Agent: TIMOTHY FOLEY SMITH, BUCKLEY & HUNT INSURANC 152 OLDHAM ST E AGENCY, INC C/O COMMERCIAL BOILER SYSTEMS 500 FOREST AVE PEMBROKE MA 02359 BROCKTON MA 02301-5749 Agent Code: 6201120 Agent Phone: (508)-586-5432 COMMON POLICY DECLARATIONS i return for the payment of premium, and subject to all the terms of this policy, we agree with you to provide the insurance as tated in this policy. iOLICY PERIOD: From: 12/23/2010 To: 12/23/2011 at 12:01 AM Standard Time at your mailing address shown above. ORM OF BUSINESS: INDIVIDUAL IUSINESS DESCRIPTION: PLUMBING CONTRACTOR >rrfs policy consists of the following coverage parts for which a premium is indicated. This premium may be subject to adjustment. Commercial General Liability Coverage Part Total Premium for all Liability Coverage Parts Terrorism Risk Insurance Act of 2002 and 2005 Coverage Total Policy Premium DBMS AND ENDORSEMENTS xms and Endorsements made a part of this policy at time of issue: pplicable Forms and Endorsements are omitted If shown In specific Coverage Part/Coverage Form Declarations )rrn Number Description 32170 -0108 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM 32176 -0108 EXCL OF PUNITIVE DAMAGES RELEATED TO CERTIFIED ACT D003 -0907 CALCULATION OF PREMIUM 3017 -1198 COMMON POLICY CONDITIONS „J21 - 0702 NUCLEAR ENERGY LIABILITY EXCLUSION (BROAD FORM) -57(06/94) INSURED COPY PREMIUM INCLUDED $ 1,157.00 $ 15.00 $ 1,172.00 r 'A Date... 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... has permission to perform ......... ....... ......... wiring in the building ofleo 'A 4 .4, 612t --� .................. .... ........ . . ............. North Andover, Mass. Lic. N -.j ... .. ....... . ........ I LECrRICAL IiN�S;P'�EC;Ti�Oik� Check 90.76 Commonwea& o f /f laebachaieEtd Official Use�{On'llvv Apartment artment o p.}ire Services Permit No. _! (J J Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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: October 7, 2009 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) 50 Royal Crest Drive Building # 10 Unit # 8 owner or Tenant Royal Crest Apartments Telephone No. 978-681-1822 Owner's Address 50 Roval Crest Drive North Andover. MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Residential Apartment Buildings Utility Authorization No. Existing Service Amps New Service Amps Number of Feeders and Ampacity Volts Overhead ❑ Undgrd ❑ Volts Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters III L#CIL111 VVIII 1.7 LJI.7L LJI111GLiL LJYG LV ILGIICIIIL LJGIIILJ. .7IIVLrnGV: h Completion of the followine 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 ❑ n- ❑ rnd. grnd. o. of 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 Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum 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 K71 KW ecurity Systems: No. of Devices or Equivalent No. of WaterNo. o No. o Data Wiring: Heaters Signs Ballasts I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $ 200,00 (When required by municipal policy.) Work to Start: 10/06/2009 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no pen -nit 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. FIRM NAME: The Electricians & Co. Inc. LIC. NO.: A10737 Licensee: Michael Parziale Signature LIC. NO.: E20269 (If applicable, enter `exempt" in the license number line.) Bus. Tel. No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt. Tel. No.: 781-322-3100 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001021 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. $ ® • 60 1 � p� l0 _ 2� ��� T Gtr �'� �� '�