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Miscellaneous - 103 SECOND STREET 4/30/2018
f Date ... V . 0/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1 �' 1.j 2 2C'1�l a tY\ Z2 i Thiscertifies that......................................................................./.�.....................C......-................. has permission to perform ..-Q.42A..:........5......,..c+ o!?�� ....... wiring in the building of :...... ., ....? .. ....................................................................... at ..........1,L,r,,,,. .P,(',Yl,;ri„ q,,,. l �— 4 , , North Andover, Mass. ......,.�...AA.................. 1~e Lic. No. Z.- .....'.!�....... ... ............................. TRICZINSPECTOR Check # .J M Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. t/tY Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 8 'I Q 2 Q ! 4y City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givesno ce of his or her intention to perform the electrical work described below. Location (Street & Number) ,%05- sec(/d S'T •� ,,��N0 F �.i !1� Owner or Tenant P AV i O y l01 1 AOW, Telephone No. Owner's Address S A-^ 4L loe Is this permit in conjunction with a building permit? YeA No ❑ (Check Aro riateBox) Purpose of Building Utility Authorization No. QT L 3 ` Existing Service Amps / Volts New Service 30-0—Amps 1 2410 Volts Overhead ❑ Undgrd ❑ No. of Meters Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Rew7ne A 9,4 rLor r~ N T No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA of Luminaires Swimming Pool ove ❑ In ❑ 2No. rnd. nd. 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 o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eatum Totals: Num er .... ..... T ........... ons V .............. ` ----� o. ofSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local []Municipal E] other Connection No. of Dryers Heating Appliances KW Security ystems:* No. of Devices or Equivalent No. of Water KW Heaters No. of o. of Sf s Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: pp • Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value ofAlectrical Work: All 009• (When required by municipal policy.) Work to Start: �, i / 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 Jr BOND ❑ OTHER ❑ (Specify:) I certify, under the sins and enalttes of perjury, that the information on this application is true and comple /�j FIRM N : trrAW J &m I N lft � L.V#-"fAI � w'L r � LIC. NO.: 7� TG Licensee � i SAI�INq Z L j Signature LIC. NO.: 94fry `' (If applicable, enter ` m t y� the licenser line.) Bns. Tel. No �• Address: i�c i i.t+ + . %� G 1 • R �4 O1 �jyy Alt. Tel. No..: *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 a ent. Owner/Agent Signature _ Telephone No. PERMIT FEE: $Z I g. s ea z 1 0 ox O/Z "A yThe Commonwealth oflt2assachusetis Depaiftent of.IndosiWal,Accidents Office oflnvestigatiow 600 Washington Street Boston, MA 0.2111 vww.massgov%dia Workers' CompensationImuraneeAffidavit: BixilderslCouixactorsyleeWeiansiplumbers Applicant formation. Please Print Legibly Namap.usiness/organizationanaviduat): C—W^Tr11. % w E " r-ccraA c1. �i1R C Address: //o 7rPkCksaN Sr " IU -As. City/State/Zip: l' MU eav j KA Q1 s qct Phone #: q79 - 687- - 5 2 tr Axe yon an employer? Check the appropriate box: Type ofprgject (required): 1. foI ami a employer vvith�� 4. Ci I am, a general contractor and1 6. F1 New construction employees (M-andlorpart tim.e).* 2. ❑ X am a sole proprietor orpartaar- have hired the sub -contractors listed on the attarAed sheet t 7 ❑ Remodeling . ship andhaveno employees These stzb-contractors have 8. Demolition workiug for me in. any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 4. ❑ Building addition required.] officers have exercised their 10.[] Electrical repairs or additions [3.[El. I am a homeowner doing all work right of exemption per MGL, 11.[j Plumbing repairs or additions myself [No workers' comp. c.152, §1(4), and wehave no 12. Roof repairs in enran ce required.] t employees. [No workers' 13.0 Other comp, insurancerequired..] 'Any applicant that checks box#Z must also fit outthe section below showing their workers' compensation policy information. ?Homeowners who submitthb affidavit indicating they are doing all work and then hire outside conf dors must submit a new afiidaMadicatiug sucl kx' ntradors that check this box mnstaifached an additional sheet showing the name oi:the sub-coniraeinrs and their workers° comp, policy information. I om all employerihat isproviding workers' compensation imuranceformy ernployee.s Below & thepolicy iwdfob site information. Ius'uranceCompanyName: P41--r9amo ;PNStIRA• zG Ca Policy # or Self -ins. Lic. #: 08 W EG - (~ F- 4 3q 1j.- Expiration pate:_ ;i (o lo/ 11.r rob Site Address: 0 3 los, SEC rye� ST esiy�S`tzate�Zip:lll • 1 e—� �lA 019yr Attach a copy of the workers' compensations policy declaration page (showing the policy number and explimtion date). Failure to secure coverage as required under Section 25A ofMGL c.152 can leadto the imposition, of criminal penalties ofa fine up to $1,500.00 andlor one-year imprisomnent, as well as civil penalties in. the form of a STOP WORK ORDER and a tine Of up to $250.00 a day against the violator. Be advised that a copy ofthis statementmaybe forwarded to the Office of kvestigations o1:'tlte DIA for insurane f coverage verification. I do pains Adpenaldia ofyerjuty ihtd tke informrciionprovided above is trugand correct. Official rise only. Do not write in this area, to 25e City or Town: by city or town official PernilMeense # Tssuing.ArAority (circle one): 1. Board ofHealth 2. BuiidingDepartment 3. CityJTowu Clerk 6. Uther 4. Flectrical Inspector 5. Fluff nbing hVector ContactPerson: Phone #: 4-11 s i Date .. �/ .1k. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... (..!........................................................... `�1P C T2 C'1 r t I ........................ t ....................... has permission to perform ... Y...'e wt�✓L�.�' ✓`^'"+ U� C�i+Rs{ } (`"� ................................................................................. lvA wiringin the building of.............................................................................................................. Qat .....�.� �, �(;�5+�-k. ............................................................................ North Andover, ss. Fee... ..`...Q .............. Lic. Nol�L►...i....................................... ................. ELECTRICAL INSPECTO Check # �2 4-1 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Z zy 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: QQ -I Q • Z c) / y 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 electricaIXork described below. Location (Street & Number) 10-3/1W .SC" CO--vd Sr " 1 5t Flom Owner or Tenant Y AV 1 0 A440114 -vi Telephone No. Owner's Address S A-^ Is this permit in conjunction with a building permit? Ye No ❑ (Check Appro riate Box I� Purpose of Building Utility Authorization No. 1 Z Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 30-4—Amps 1 14 a Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Rew'taa A 9,4 flar MCN T ('.mmnlvtinn nftha fnllnwi— mhla -- ha umi..ni71— A. 7..0..,..i.,. ..f W,' 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 Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting B tteKy Units No. of Receptacle Outlets No. of OR 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 g No. of Waste Disposers Heat Pump Totals: Number"T ons "' ""''" KW "'"""..""._..... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local F] Municipal ❑Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Si s Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: /I,- /� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of,Electrical Work: �10 00y. (When required by municipal policy.) Work to Start: fr/12, 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 c verage is in force, and has exhibited proof of samd to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I cern!&, under the ains and enalties ofperjury, that the information on this application is true and comple /� FIRM N om! fit, l•. t N % L,�L'T�t f. Al /�+ ` LIC. NO.: �� 2 A Licensee%1 Y 'TAI4NIr I l.j Signature LIC. NO.:3 94..0 I; (If applicable, enter e m t y� the license line.) 1 Bus. Tel. No �• Address: Ito N4 ,.i: t0• G 1 �'1 K4 O I pjy I% Alt. Tel. No.: c! *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. VTJ 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: $Z,1 8. STATE -2 OP ID: AA CERTIFICATE OF LIABILITY INSURANCE DAT 08119DIYYYY) 08/19/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 781-914-1000 TGA Cross Insurance, Inc. 401 Edgewater Place, Suite 220 Wakefield, MA 01880 Dianne Werbner CONTACT NAME: Cheri Rossetti acoNr o E>tt : 781-914-1079 FAX No): 781-246-2601 ARIL : crossefti@tgacross.com INSURER(S)AFFORDING COVERAGE NAIC # 06/01/14 INSURER A: Employers Mutual Casualty Co 21415 EACH OCCURRENCE $ 1,000,000 INSURED Stateline Electrical Service Phil lannazzi INSURER B: Hartford Insurance co. 02231 INSURER C: 110 Jackson Street INSURER D: Methuen, MA 01844 INSURER E: $ INSURER F: AUTOMOBILE X COVERAGES CERTIFICATE NUMBER: REVISION NUMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTSRR TYPE OF INSURANCE INSRADDL SWVD UER POLICY NUMBER MWD LICY EFF POLICY EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FXI OCCUR AUTHORIZED REPRESENTATIVE 5A1391715 06/01/14 06/01/15 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 100,00 MED EXP (Any one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 X binkt addl insure GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECTLOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE X LIABILITY ANYAUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS BA3573696 06/01/14 06/01/15 COMBINED SINGLE LIMIT 1, 00Q00 a accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ (P ) PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 5J1391715 06/01/14 06/01/15 EACH OCCURRENCE $ 2,000,00 AGGREGATE $ 2,000,00 DED I X I RETENTION$ 10000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If S6 describe under DESCRIPTION OF OPERATIONS below N / A 08WECCF4394 06/01/14 06/01/15 WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER rAlUrFI I ATInm TOWNANI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Dianne Werbner ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 10 �``' This certifies that .1 ...... C� 2 0 0 .............. 4 ............... ... .... ....... has permission toperform.'.) ... I! .............. C ....... 4 ...... —... .......... �16 plumbing in the buildings of.... qo 11,4 , 11 ..................................................... ............................. at ....... / ..... 0 ... 3 ......... I ... Ie... _aa� ................... .................................... North Andover, Mass. Fee.:!�W� . Lic. No. "........................................................... Date Mz.q.)RU . .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Check # .3 L4 PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUM�B�ING WORK CITY d,eaJ`e�/� j MA DATE �S� [ PERMIT# �yUP JOBSITE ADDRESS STiC�—e L� OWNER'S NAME �-1 .f�� POWNER ADDRESS TEL ---FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: E—J' REPLACEMENT: Q PLANS SUBMITTED: YES EI NO© FIXTURES -1 FLOOR -4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEMDEDICATED GRAY WATER SYSTEMDEDICATED 9-1 WATER RECYCLE SYSTEM :DISHWASHER ._._..—) __. __i ...__. _( _—. ► _� ._.__ i ._._-._-j .___-� _..._ 4 ___—� _.1 i } 11 DRINKING FOUNTAIN__.-_( ......_J FOOD DISPOSER - i FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN 3 ___I ____4 ._ �( ___( _____J __ _ ._._.__[ .__...-__ # .._._._( _ __ _.._- ► ___� __ SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _( WATER PIPING OTWER I t wl T INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [9 --NO NO _l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _f 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 Q AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME @LICENSE# -�53 i SIGNATURE MP JP CORPORATION _kl o �{ r PARTNERSHIP O# LLC EY COMPANY NAME @ p L / ,� ADDRESS Ie� CITY 1 GfLf STATE / ig ZIP a,� Zz TEL FAX _ € CELL �� EMAIL ! z oED fA EDj ry The Commonwealth of Massachusetis , - Department oflndustrial Accidie is Office of Invesfigations 600 Washington Street .Boston, MA 02111 -www.mass.gov/ctza Workexs' Compensation Ynsuxance Affidavit: BufldexsfContractoxs/Electricians/PIiimbexs Auplieant Information Please Print Legibly Name (Businessiorgani'zaiionikadividual):�, ;�(,>e)rLI Z>4'Fze-z� ct,- Dx3 --LSC Address: "/a- City/State/Zip: :MJ -2 r Phone #: he � SJ Are an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 3d 4. F1I am a general contractor and I 6, E] New cdnsiruciion f employees (full and/ox part time) * have nodthe sub -contractors `7. "modeling 2. E] I am a sole proprietor orpartner- listed on the attached sheet. t ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp, insurance. 9. ❑Building addition [No workers' comp. insurance S. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all woxk officers have exercised.their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofxepairs insurancere ed. a employees. [No workers' 13.❑ Other comp. insurance required.] XAny applicantthat checks box#I must also fdl out the section bel6w showingtheir workers' compensatioapolicy information. T'Homeowners who submit this affidavit indicating they 9dying all work and then hire outside contractors must submit a new affidavit indicating such. /Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees: Below rs the policy and job site information. c— Insurance Company Name% lfx e! 1 Policy # or Self ins. Lie, #: ExpirationDate: ,5 lob Site Addressle 3 as AXTA %'PI)CJ City%State zip: Attach a copy of tete workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as re qu*ffe dunder Section 25A ofMGL e. 152 can lead to the imposition of criminal penalties of a fine up to $1,50 0.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORM 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 cert& under the p'afns and penalties ofperpry that the in• formation provided above is true and correct. Official arse only. Do not write in this area, to be completed by city or town official City or Town: Permi-Mcense # Issuing Authority (circle dne): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Phone Information and Instruction s Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an errcployee is defined as "...every person in the service of another under any contract ofhire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore of the foregoing engaged i a a joint enterprise, and including the legal representatives of a -deceased employer, or the receiver or trustee ofaa individual, partnership, association. ox other legal entity, employing employees. 1%wever the owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such, dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or p ermit to op erate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required2' Additionally, MGL chapter 152, §25C(7) states "Neither the Commmonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill, out the workers' compensaiion affidavit completely, by checking the boxes that apply to your situation and, if n®cegsary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicyis required. Be advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate no City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Ofii.c0 of Investigations has to contact you regarding the applicant. Please be -sure to fill in the permit/license number which will be used as a reference number. iu addition, an applicant that must submit multiple permithicense applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Yob Site Address" the applicant should write "all locations in(city or towm) 2' copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit -is on file'for future permits or licenses. Anew af(xdavit must be filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone aid fax number: Tho C!axr_>moawealth of Ma ssa c,4v Depatiment d1ndusWO .Accldont QfiRce QUTAVesifgamm 6bG Wasbggto a. fteet BQstw, MA 02111 TO. # 617-7-2.7-4900 -4.900 e:.Kt 406 Qx 1-87T ASS.AFE Revised 5-26-05 Fax # 617"727'7749 �vx>�ass,g¢v�cl7`a Date . 4h ll ••• TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..................{` l............D....�k................................................. has permission for gas installation..��ps........�`.G..��..s. 4 114 -in the buildings of ....`..........:........:................................................................... U 3 S�� a,. ........ , North Andover, Mass. at .............................. ........ ...... Fee................. Lic. No... T 2 ... /✓. ................................................... GAS INSPECTOR Check # V% -'-S4 0 . r n/" 7/2 3//`f { MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �dit� fJD� c��2( MA DATE -Y PER JOBSITE ADDRESS OWNER'S NAME G LL-- - FAX ,p OWNER ADDRESS TE TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ® RESIDENTIAL CLEARLY NEW: 0I RENOVATION: Uj--' REPLACEMENT: El PLANS SUBMITTED: YES NO Q APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE j FRYOLATOR FURNACE- -z_� _ i GENERATOR �:_.�,I I I �_�I _ �.-�-� _ 1 � ( �J --- GRILLE INFRARED HEATER LABORATORY COCKS ��} JI — MAKEUP AIR UNIT_ OVEN POOL HEATER ROOM/ SPACE HEATER J ROOF TOP UNIT - TEST UNIT HEATER UNVENTED ROOM HEATER - C3fHER HEATER- -.. - - - - h INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES EJI'O El 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2' OTHER TYPE INDEMNITY [j 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 0 AGENT Of SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFIT ER NAMEd&Zj/,,ep J LICENSE # �_o� SIMATURE MP [2fMGF D JP 0 JGF Q LPGI CORPORATIONS]# e PARTNERSHIP ©#= LLC _ COMPANY NAME: ��y(1 rrp 1,� -_Z!j ADDRESS Cef CITY /. �.�G �. __ = --I STATE �ZIP 4= 2 TEL FAX 1---. _- J1 CELLL EMAIL FA m Date .............. ..��:l.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......1.1 ..0 A ................ Iz.acl. e..... ...1, (a. -................................. has permission to perform ........ ......S -C R j < <-'e'er' ..........................................1.............................. wiring in the building of......... .l.�. ...�............ N O ( .t"'..o ...................................... �T o h Andover, Mass. 04 at........��...................................................... ►-Fee.......J. ......... Lic. No...... C�..!¢ . ......... E TRICALINSPECTOR Check # / -. J Commonwealth of Massachusetts Official Use Only p Department of Fire Services permit N o. 2-5-� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ptev.1/o7] peave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 52 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION Date:—? a 2/ y 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 t}te electrical work described below. Location (Street & Number) 10-3 Sec o w % 9r Owner or Tenant D A*/ 0 H p I A N y Telephone No. Owner's Address S_ "C Gly fT (9 1"-7. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building - Utility Authorization No. 13 A Z Existing Service Amps / Volts New Service / W Amps 110 / 21+/0Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead" Undgrd ❑ No. of Meters Comaledon of the following table may be waived by the Imnector of Wires- 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 Swimming Pool Ab oe ❑ ❑ ° Uf Emerg�� nits No. of Receptacle Outlets No. of Oil Burners FM AT No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Toota No. of Alerting Devices No. of Waste Disposers eat Totals: amber ons o. of ntain Detection/ Devices No. of Dishwashers Space/Area Heating KW Local ❑ Connum�ecti�on ❑ Other No. of Dryers Heating Appliances KW ecunky Systems.* No. of Devices or Equivalent No. of Water KW Heaters o. of No. of Signs Ballasts Data Rrhiug; No. of Devices or f4uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or uivalent OTHER: Attach additional detail if desirea4 or as required by the Inspector of Wires. Estimated Value of 14ect i Work: U V, (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 p afif es of perjury, that dte informadon on this application is true and cornphft�1 FutM NAME: grwviL;-M E L_ Pzn^t 4-k L , T�` LIC. NO.• I ( -71qz A Licensee: r itis t fJ T,O (If applicabk enter `g. A Pt 11 in the Address:sAG If t �- LIC. NO.: *3 Y ysy t H Bus. Tel. No.: Aft. Tel. No.: *Per M.G.L c. 147,-& 57-61, security work requires Depar mens 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 FLEE: $� e 1. -0 LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 978-256-8586 Fax: 978-256-8590 April 4, 2014 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845-3616 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845-3616 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: DAVID HOLLAND Loss Location: 103 SECOND STREET NORTH ANDOVER, MA 01845-3616 Policy Number: PHOO100834362 Date of Loss: 4/4/2014 Cause of Loss: Fire LA File Number: MA -2-24342 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Kris Kirkpatrick Adjuster LaMarche Associates, Inc. - 800-349-1525 Page 1 of 1 Location t� L' r _ No. `� Date �4 w NORTh _ TOWN OF NORTH ANDOVER - p Certificate of Occupancy $ r Building/Frame Permit Fee $ J�CHust Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector _08 50.00 PAID "' `' Div. Public Works W i a � m 1! I W � z N W N v IL X I X in �, N us Z > 0 It O Z WN Z a 0 m s �( J' 0 ] WN N LL e~C OLL 0 0 0 z F Z Q. O LLI Y O Z O Z W K NW W N < E D N d Z m m y m 0 W tind ^ 0000 Z o u C% a z z H p 0 0.1011.�ajai < W Ir N <W < ..+ W Z Z Z < O N Z 0 Z z <F O O N N U N W W C U wz Q W u W W U = < Q N ? N O O< m O M LO 1 L N N n0. N m W 0 m W C N W O N xLW X x I Z 0 0 z ] O LL LL O F I O W I W i al, z 0 4 I a W z i u x Z U 0 LL O 4 J LL O W W < N N f P. z O r 0 O N I N W 0. i 8 C c -a _ S � V✓ J LU V H H J W 3 F o �� § o U O U V = S ` N Z 0 O J r < F U J ] W W G + O Q Z W 13Z N O �_ 2 0 F J H m ] z z 0 N m 0 m < ° � m � N Z 0 > W N d1 rc Ir O U. mO d _ ZO Z < IS �N N U Z < Z O Z O mW N C p \ h N ] < W W f N c [� J 0 a Z N N N j W <m t f 0 0 O m t 0 Z N J J i O N W _ < C N u LL F m W w W ►�- W < N Z W W Ur (1 1- < I -Ur W C N d G W < d O N 4. 6 4 N -1 A ti N T0 0 D T C. n n D; N V 8m; 0 C) �ro DOVv'D Dw rn ooZnn CcnmoOJOD A DIOL JO w m'OOO vclZ r 0 rp.moy~mm mm(Z'17nC 7cnn~NDO�� Ow D N7nc(Z Z N y_O a =Na Nm�O OHO(j> -• C M; Ow 00 000OO^OD O"Z.mmayi ym . T H23:OO =nZ; O 2006112n Z C, D Z;TO2ZCO m Z;0ONC3DO� >>20T Qps =DZ ZO D<;mD3{ 1n II 1111111111 IIIIIIIIIII111 _ I _ I C JI N �� R Zm2oc >mx ,:2 tit;OZx �-m D� D nx n ;T TT cpv2v .� QN Om'- ZDpp Ov .� r�pDQ DDOD O -� �n0 AAO l0 0 ZZ Z<D DZ� C y y2 CDA, mmmr r) , - m T; Z O T om r0 D _ m Z p f; O T iv r O A y x O Q n n x s O= m p T D N Z` y O n m A Z m JO yn yZy N D0ZSCZn pw Dp y .O Z y ti3 D A� -{ NN ci 'Mom, x0 QOTOOm N<33T mA N rZ xr) O 0 Gl A -i f Q A S p X c Z Z _ x r a T ti '^ D D Z Nepro DZ Y c ppx yN C f T '- i mm a 0 ZD A;~ n T �-L I I I I�O Z DD III Z n �JO Zm O X MOTH VI N ril p- �LJ_L_1 I L _ I� or c P v_ Z m n 0 v YI La 16 5 a I o I Lo -r,68 c 7 Lo-� II 51514 J 'i; It91 IC�UOit$I,HC IC: ;ui!;;rt' Itnl IuG+��. o `r i?- MORTGAGE 2 MORTGAGE INSPECTION PLAN BUYER 4,A 161\Y10 O LOCATED IN TO THE OAQk rQj�'_ 6A\11046 AND ITS TITLE INSURERS MASSACHUSETTS I HEREBY CERTIfY THAI I H4kV9 EAAMINEU 'INE FREMMES ANU ALL EASEMEN141 ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN. I FURTHER CERTIFY THAT Tj1E BUILDING SHOWN DO( ) CONFORM TO THE lt ZONING LAWS AND AMENDMENTS, I.A. ( FRONT, SIDE & REAR YARD SET BACK ONLY) OF. 0.Q, AIJ ✓VV �r � WHEN CONSTRUCTED. I FURTHER CERTIFY THAT THIS PROPERTY IS Q'2T- LOCATED IN THE ESTABLISHED FLOOD HAZARD AREA. 1 NOTE : THIS CERTIFICATION IS BASED ON THE LOCATION OF SURVEY MARKERS OF OTHERS, AND DEED DOES NOT REPRESENT A PROPERTY SURVEY. BOOK EXAMINATION OF THE RECORDS I$ MADE ONLY SUBSEOUENT TO THE RECORDED DATE OF THE PAGE LATEST DEED AND DOES NOT INCLUDE VERIFYING THE .ACCURACY OF THE DEED DESCRIPTION PREVIOUS TO ITS DATE OF RECORD. PLAN THIS COMPANY IS NOT RESPONSIBLE FOR ANY INDENTURES MADE SUBSEQUENT TO THE RECORDED DATE OF THE LATEST DEED OF RECORD. NO. WHENEVER BUILDINGS ARE SHOWN LtSS THAN ONE FOOT FROM THE PROPERTY LINE IT IS BOOK ADVISED THAT A MORE PRECISE SURVEY BE MADE TO VERIFY THESE MESUREMENTS. PAGE THIS CERTIFICATION TO BE USED FOR MORTGAGE PURPOSES nn11,Yy CERT. NO. _ O,, ,.A.., _ J�1_ BRADFORD ENGINEERING CO °. SCALE : I" • Zp' �. P.O. BOX 1244 Haverhill' MOSS 01831 James ; TEL. �I UKA.'i s 373 2386 ,` ` 9 [: t li I \ 3, �, l ..ISI t• `�./. -. S(Ik Jfyc� <<c• J 6 9 DEPARTMENT Of PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE luaber: Expires; Birtbdate-. CS 049832 10107/1998 10/0711953 Restricted To: IG -W ALAN F SABATINO PO BOX 464, BYFIELD, KA 01922 __' ��, }}�. Offica Use Only� I( t u�1E LIITItTnIIn11TEi of ��rllu�l1� Permit No. 7 r s +9e;rzr=ziT2 af,'Pu6lir _5-af tlq Occupancy & Fee Checked - - 3!190 (leave blank) ' lam BOARD OF I -IRE PREVENTION REGULATIONS 527 V-0 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 MSR'-1�0�0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (j� or Town of NORTH A t�nOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number)t 0 3- 1 SECic5l" Owner or Tenant Owner's Address _ Is this permit in conjunction with a ouiiding/permit: Yes v/No L- (Check Appropriate Box) » Purpose of building¢ � Utility Authorization No 1 (� /� Existing Sanrice fib- Amps Z���Vcits Overhead '✓ tlnagrnd 7 No. of Meters New Service Amos -_/ Voits Overhead _ UncS.he _ No. of Meters Numcer of Feeders ana Amoacity Lccacicri anc Nature of Proposed. E;ectricai NCrK No. of Ligrang Outlets Nr+, of Lighnno Fixrures No. at=ecectacie Outlets No. of Sw:tcn Outlets No. of Ranges No. of Oiscosals No. of Qisnwasners - No. of Dryers No. of Water Heaters No. Hvarc Massage Tubs K`N OTHER: 1K1F_f'L lk No: t pct las IAbove— in - Swimming Pool yrn1.3.o.— I No. of Cil Eumers w j No. cr Gas=urners Total No. at Air Ccrtc. tons, No.of Heac Total Tocal ? ; ^Ds Tons KW SoaceiArea Heading 1 Heating Oewces �w No. at - No. of Sicns Ballasts No. at Motors Total H? Tocat I No. at Transtormers KVA.-....- i I Generators KVA No. at Emergency Lighting Sarery Units FIRE ALARMS No. at Zones No. at Detection and initiating Oav ces No. at Sounaing Devices No. of Sea Contained OetecnaniSaunoing Oevcces Local -' Murncieal Other connection t_ow voltage Winnc EU3 F "jk7— INSURANCE COVERAGE: Pursuant to the recuirements at MassaCnuss -s general Laws _ _ I have a current Liaotiity Insurance Policy a inciuccng Cmc:ecee Ooeranens Coverage or is substantial eauivatent. YES _ NO nave suomcnea valid proof of same to the Office. yES _ NO _ It you nave cnecxea YES. please cnaicate the type of 'overage cy cnecxcng the aoproar,we 13(3x. ll Q �lys�r cA�c�2 INSURANCE = 30N0 = OTHER) = tP'eas Scec:ty) ( oration Oatet Esamatea Value of Ecectncal Work S �° - - Fi - n Rou 1 al Worx :a Start��!illtdJJ� Inscectcon nate Racues:ec_: g• Signea unaer the Pe itces at per>u�ryl c c �Z�'S"� 7 y tL9l�E H J A'SA.77a'(� LIC. NO. Signature LIC. NO.- L:censee /f^ t r r7f j�I� / r/d�✓L Bus. :el. No. Acaress 1l of ti i f G r 7 alt. Tet. No. OWNERS INSURANCE WAIVER: I am aware that the C:censee eoes not nave me insurance coverage orxs,suostannat eaucvalerAgerte- ou:reo oy Massachusetts General Laws. ane that my signature on :n:s derma aooucanen waives this reaucrement. Owner tP!ease cnecx ones sYr����/((// –etecnene No. PERMIT FEE S (Signature at Owner cr Agenn A Date .../0/ /. .�.- 26 t HORTI{ 3?;!t<r^^�1�-0� TOWN OF NORTH ANDOVER PERMIT FOR WIRING +► oma- `���� f ,SSACHUS� This certifies that—... t.r. .u.......... ............................................. 1 P has permission to perform ...... .......... wiring in the building of ....'4 . �` `''....... C,1, ,� d ................................................................ � � S at ..�U..�.. ...°...................<................................. , North Andover, Mass. el Fee...... s ..�`� Lic. No. �%.�S �`{ ............................................................... ELECTRICAL INSPECTOR 0/18/96 12:09 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 3;7 Date ..... z -7.-.n).2.. n. ..... ORT" TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... . ..... a . . ...... ..................... has permission to perform ....... .............................................. wiring in the building of ....... ............................................... at orth Andover, Mass. Fee 46................ Lic. No. ...... ..... .......... .............. ................. c�?�-Jj 61 , '.-ELEcTRICAL INSPECTOR F' Check # ---• •- v . v� f I/Jw! MAN LL -LU I k1L;AL SERV PAGE 01 ccone �CC�_� iia �t.� Official use Only Q c�t�'R�wte>r./ n�,..yYre ..�er+vilJsS Permit No. � ! /,k V O=qmcy acrd Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (RC -1099) QWCb1-*) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wox* to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 12.00 (PLEASE PRINT IAFIIV OR TYPEAki� INFO ION) Date: 71a, Z City or 'own d- / t� G l �Ado V e y-- To the Inspector of Wires: By this application the undersigned gives notice of Itis or her intention to perform the electrical work described below. Location (Street i& Number) _ Owner or Tbriant h c-, Ownet's Addvess 10 C 5- 3 -16, 6 c cc>n ct to n' Is this permit in conjunction with a building permit? Telephone No. artk �jn�a tr er 11% ct, , 0 t '?V-; Yes i+-� No ❑ (Check Appropriate Box) Purpose of Budding Utility Authorization No. Existing Service _22tL— Amps Voits Overhead e Undgrd ❑ No. of Meters a�- Ne�3ervice — Amps L ts overhead ❑ Undgd Q No. of Meters Number of Feeders and Ampacity Location and Natwe of Proposed Electrical Work: fahro ..nv lie u.n:..ed rwil,s r. ren ..fes No. of Recessed Fixtures No. of Cei] -Susp. (Paddle) Fens, No. of Total Thnsformers If VA No. of Lighting Outiats No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Ag e D B t �c�' lg ting ty No. of Receptacle Outlets No. of Oil Bumcm FWAI No. of Zones No. of Switches No. of Gas Somers o. of Detection and Initiatin Devices No. of Ranges No. of Air Coed. Total No. of Alerting ]3evices No. of Waste Disposers Real Tis IytitlDi7€iC _ _ Tons _ _ _ _ _ No. d of Se! ontttine Detection/A,leartiii Devices No. of Dishwashers Space/Area KeatingKW Local ❑ umecdottn Other C No. of Dryers Heating Appliances BCW yys� echo of�evices Equivalent No. of Water Heavers Heaters KW No. of No. of Signs or [n Data Who' Ballasts No. Deviot:s or Equivalent Na. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No_ of Devices or 'valent O'TIiER: INSURANCE COVERAGE: Unless waived by the owner, no Aunt* oddfeienw decal if desired, or as required by the /eaptctot of Wirer. 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 certities that such coveragt: is in force. and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE E!r BOND ❑ 0TjjER I (Specify:) Betirnated Value of Electrical Work: �3.r0, o o (When uued �"p"atiO° ice) reQ i ` by municipal policy.) Work to Start: 7/L 316 �)- eons to be requested in accordance with MEC Rule 10, and a 1 Celli& under the pains end penalries of peduM Acct the ' pori completion. snfna7nation on this appttcatiort Is true end cmnpiere. FIRM NAME: �.CC a S'4qa- R v 1C � $ ^'N C . A� c.1ti V- i Leo. No.: Ea P&i?s Licensee: t • � t ; tff applicable, armee rxvve" un the Ilan r nunebrr li � $igtieltAUe LIC. NO.: /4 / `Q Address: /V u �,. S {7 Bus. Tel. No -_ OWNER's nvsuItANCT? W ��► v Q i`.� M1� 3 AVER: I on awl th itt the Licensee does not have the liability insurance AIL Tel. No.: Rignature below, l hereby waive tllals g gtriirmenL I am the (check one coveuage �a0n'Wly �� by law. By eery Owner/Agent ) (..� owner ❑ ownee's agent Signature Tticphone No_ PERMIT FEW. S ToNVIdnC4Nf4Mrkjnfing 1.alOOJke�.t y*.v,,;,. ,sa nirof UL -23-2002 TUE 03:33PM ID: