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Miscellaneous - 105 AUTRAN AVENUE 4/30/2018 (2)
I Location No. �/ Date / "a • NORTH TOWN OF NORTH ANDOVER 3? � •• OCL ` Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check #-33- F . 18 4 7 0 ~Building Inspect ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r. BUILDING PERMIT NUMBER: 13 DATE ISSUED: SIGNATURE: 11IJ is Buildin Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: " (a u lrdn Alen ue I` I r 1 (� 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts R 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided ti 1.7 Water Supply M GL.C.40. 54) 1.3. Flood Zone Information: Public 0 Private ❑ Zone Outside Flood Zane ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENTr�. ! a 2.1 Owner of Record ,� i i��G�' Pc r ► _ i w ✓Ili lyay) Aye- NAY Name (Print) r+ Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licen'sted Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone OU rn X r -'al z O v rn 0 z M 90 0 r v rn r r E G) J t ' SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 f 25c(6) a Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building it. Si ed affidavit Attached Yes .......❑ No.......0 SECTION 5 Description o[ Proposed Work check ae applicable New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other 0 Specify A. i Brief Description of Proposed Work: Aklkm'�1111) 46 pt�'& 1 LECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed b tnrit applicant OFFICIAL USE ONLY __: 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) J7 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, r as Owner/Authorized Agent of subject property Hereby authorize to act on My�If ui all matters relative to work authorized by this building permit application. Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are L*ue and accurate, to the best of my knowledge and belief Print Name L' Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2' 3 KV SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DMNSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 CA CL4 c >, cdcd cc x n b 2ami >' = x H cl cit >> U > y O m r �, MO ami as iL Vi Z Ocq3 w U E y 0 at%i c o °° U O o °' ticU° y cz ° °" N on u 3 to cz C o m N ObA , n C m bA O 3 o N 'L7 00co 1G ^C H y O O V N «Y o acz � ami > o `� z 0 = U O 00 � V en 00 O n N N `i C. 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R ... >, — U -a .sr o o o ccs �, a� — U p s A, ccs "' o s. <+. O .� C y Oy b �+- a cs a s .�, y ti .� ccs w H bA U Cl. in C U 3 er~ >, R N �, U Q Y `n Y CJ n� rA •�-, U .- 0 '- .r— U U 0 +- ° 0 N w Q y lg? N ai >, N .0 � = +=+ TCA 00 M 3 3�M, ui:-aa= "G��a�a; cw�c dao E caO arm � L n ca E� a�cona n o n cc c�o ��-� a�� a�Uxo c�oU • n>o�Ts an o o b OO s Er at ca . c a� a . a U.rr M a' oo ° [— cz N U .D 7✓. ++ U i-'�. Lr N �� U U U N Y O-.5 U O. y y 3 OU 04 7 s. x t. C `*"t"' p ° � U U G% U •�U Y 'a ~ Yf1-, � `� I-+ U U y � f- s]..- � +.+ cc O. S O O n C U a E to O0 U a o-zj s; o sr 00 R% > O C. -a `p ..�. N '3 [�. «i A to ° Sal X U n a= U — �u Z'� U a °�' o ° U °' obi o �� ��•°' 3 �-° °� E °' n >, bA �" Q bo ?, w ccs °_' 0M O P+ rs o0 —• �- °"a� Boa °"S' o o Ln 'C�j .a 3 a cp U a> U c E E s�..x o � a) m � o U Q i O se O S -:O c0 ni f U , N O , --WOOD STOVE 1NSTALLAHON CHECKLIST Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stave installation and not to the stove construction. Stove A. New Used S. TypeJradlant Circulating C. Manufacturer I -ab. No. Name/ Model No. Collar size DimensionslHeight Length Width Chimney A. New Existing 8. Size (flue areal C. Other appliances attached to flue (Number and flue size) D. Prefab (Manufacturer—name and type) E. MasonrylUned Flue liner Unlined F. Height (refer to diagrams) cap aVEZ ICS 2 MNL 3� Mlt•l a CHIMNEY HEIGHT Hearth (non-combustible) A. Materials IZ`r hltfl. t 2,� MIK t8�' bt►N. HEAHTH G. Sub -floor construction C. Minimum dimensions (refer :o diacraml Clearances and Wall Protection t,see stove in--tallat:cn c!e_rances chart) A. Type of wall protection provided B. Clearances (refer to diagrams) I �� FIREPLACE u A WALLrCENTER. , I A o 0 w I o z 0 w 0 aG -� U co a w a p'' w w a a U UW W 1,4w C O r.+ � �°�° w -co c w A a aq z cn o cn D J no **Ar 0 0 I== c o E CD c h c %a o ` O N y C O r.+ CJ V c CL 'p :Ccc. m zip �a C W o� CD _00+ W Ce o.co3 Ea c m t z cc o of c : CZ c cQ EE m k •c 0 0 I== cm E h m o y r.+ cm c C � a 'p 7 m zip he C W � N E � _00+ W o.co3 b m t z cc o of c c cQ o r m ca ev a _ O�O C o `c o CLm o t ct"c o E C Z o a 5 ��=S o =�a�mzip O 0 �s Z � d O y C cm I MO E mm as O � L Oca d a ca o *-� C O Q 'p O ca C Z m CD CL C..± Na O C C C cc CL C Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION DATE: Z Z / Oct FROM: Oc�� M �► 2 t- N er rie ADDRESS: Tel #: q�8- q�SISD� Xzv/ �,- Complaint A_a q im: % -P� � ELECTRICAL. /" �S PLUMBING: GAS: BUILDING CONTRACTOR: ✓V Car BUILDING CONTRACTOR: 14 P"u ,,,, A Qe - PROPERTY OWNER: (.o,ee -(wok caoLxA oJ" Jv�J OTHER: v�u,m%-2r c►'l Ccs ���ouJ�� . Signed: Complaint form 4.03 RECEIVED FEB 2 4 2004 BUILDING DEPT. Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION DATE:��1�� FROM: ADDRESS: Complaint Against: 4 qL,—IZA?V ^jG ELECTRICAL: PLUMBING: BUILDING BUILDING CONTRACTOR: Tel #:-I78;-=�75`-744 PROPERTY OWNER: (��it/!liftA i��S/fLl OTHER: /�?W-17140-11- --4--v A Signed: Complaint form 4.03 FEB 2 Q 2004 BUILDING DEPT. Date .: � .. G...:d.`�....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ....... . This certifies that ...,....r...........................................�.......... . has permission to wiring in the building of .. r,...l...... U U at/ 15— Fee .1 ...... Lic. N .......X Check # S�y� 5181 .......................................................... .................. . North Andover, Mass. ......................... ELECTRICAL INSPECTOR Commonwealth of Massachusetts Official Use Only i Department of Fire BOARD OF FIRE PREVENTION R APPLICATION FOR PERMIT TO PER All work to be performed in accordance with the Massachusetts (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of: North Andover By this application the undersigned gives notice of his or her intention t©"pel Location (Street & Number) 105 Autran Ave Owner or Tenant Nola Imrie Owner's Address 105 Autran Ave North Is this permit in conjunction with a building permit? Purpose of Building residential Permit no. �O sa..f Occupancy and Fee Checked aULATIONS [Rev. 11/99] (leave blank) RM ELECTRICAL WORK ical Code (MEC),527 CMR 12.00 Date: 4.30.2004 To eectncafwor�crdescribe below. Telephone No. 1-978-975-1505 Ma 01845 Yes ❑ No(Check Appropriate Box) Utility Authorization No. 45172 Existing Service 100 Amps 120 / 240 Overhead ❑ Undgrd ❑ New Service 200 Amps 120 / 240 Overhead 0 Undgrd ❑ Number of Feeders and Ampacity No of Meters No of Meters Location and Nature of Proposed Electrical Work: 100A to 200A service change; instal -220V 20A receptacle, 1-110V 20A receptacle, 1-110V 20A receptacle for sump pump No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above In -No. grnd. ❑ rnd ❑ of Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones 3 o. of Switches No. of Gas Burners No. of Detection and 4 Initiating Devices No. of Ranges No of Air Cond. No of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area HeatingKWoca Municipal other ❑ Connection ❑ No. of Dryers Heating Applicances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices of Equivalent No. of Hydromassage Bathtubs No of Motors Telecommunications WiirI . Total HP No. of Devices ofEtc uivalent OTHER: ROUGH INSPECTION FINISH INSPECTION 4.30.04 Att h additional detail ifde ired..or qs regt{ira 1S3llepl1l11eS5 the es. INSURANCE COVERAGE: Unless waived by the owner, no permit for die pe ormance C5i e�ectftcal wolK 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 ❑ BONEE] OTHER (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME Power Wiring & Emergency Response, Inc. LIC. NO.: A17354 Licensee: Stephen Decker Signature A;LIC. NO.: (/f applicable enter "exempt" in the license number line) Bus. Tel. No.: 1-800-418-3221 Address: 44 Stedman St, Unit 2, Lowell, MA 01851 Alt. Tel. 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 (chec on) owner ❑o vner's agent. Owner/Agent PERMIT FEE 75.00 I Date .... 0/ �7 .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION '�ACMUS` - 4 This certifies that t...�"- .. has permission for gas i//nstalllation . in th build/ings of,r:.L./.:. :f �............. . North Andover, Mass. Fee. -/12!/V Lic. No. .......................... GAS INSPECTOR Check # 4991 - --• _ , -.- QLD u'n� \t' _ 13 Corporation - Lot u ❑ Partnership Business Tdephone�t_��q - ��[0 Firm/Cm Name of Licensed Plumber or Gas Fitter:. Nen S Aackgg" zF Q INSURANCE= COYERAGE-o. I have aliabiitykmxanm �y a. e4ent Y which -meets. She -requirements of dvlGl,Ch: 142 If You have:cheeiced-IM` *Wicaba.:U.y 4YPe= Sage by ct :fie AppooprJde:box. A HaUlty kmranceXft X ObwM tindemnify,Q Bond- ❑ OWNER'S INSURANCE.WA1VERri arrrswam:that': the11censee�does,not_fv",__the Chapgit Chapter 142 of the Mas& Genefaws,.and stmt: coverage required by my sigr�ahue =on this permit -apdicabon waives _this requirement Check one: S9nature oLAwaKOwnsrs AgMt . Ovner❑ Agent:❑ i hereby certify that all of the detafs and infonnatlon f have submtted %r ant reW in, above kr�owled9e and that ati plumbM worts and indaliations-porlom d under the application an true and acourate.to.the best.of my_ o6rtinant Provisions of the Massachusetts State Cas. Gbds and Pertnrt asuad f application will be in compliance with aft Chapter 142 a the 'le Gasfitter nat~uue of or 4+ty/Town Liven" NA*W 0 L•.' yW.. - .. ' W 06 06 z . Z OAL<' w W at d _ w _ W z ca Y p� =0 I Q W 1 _. Date.. 0.- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING US This certifies that, '4�-xf/". . has permission to perform plumbing the buildings of at . A F e e X-6 ..... LIC. No. Check # 6294 .� . ............. ... ... ...... 9 ............ North Andover, Mass. .............................. PLUMBING INSPECTOR I ACHUS UNIFORM APPLICA ON FOR PERMIT TO DO PLUMBING Prim eui'wr -Local;«, • � ` owner's Name !v '� Z<.Q, Type of New DDation D _nem Pans Submitted: Yes D No G FIXTURES Installing Company Name � a Q� �, n, -,rChec* or= Certify t _D:�i C & kWss Te!ephone _ PMWCo. Nameof i km'tber . WSUPANCE ZOVEPJW= I hm a parent labile o mr or its w owivalent which mks the � of MGL Ch. 14L Yes �[ � )� M Phase nKbcate the type coverage by king the appropriate box. A Itabrlrty b u Ance policy �j other type of indam;ty p gam G OWNEIM DISJRANCE WAIVED I am aware that the licensee by1does not ha�re the ' Ct of the Mass. General Laws. and that my s on this insurance d tai wanes this leqwWSW e of Owner or Owners Agem Owner r Check one: Agent h8 ft certify Ilial W of the deceits and Wom aticn 1 cans the best of my Wowiedge and that ap plrnroft work and orstal Q1 above action are true and accume to oe in aor arroe with an pertinent provisions at the � urr0er the pennt.issued fortlus apobcation wbl WKS IQ of me General taws. ctPkvnbw Type of Lxerree k4au, .lOtrrlleynlan L • r • • • • A • c _ ■UMEMIM�■1���e���r������r ■EMrrrNrrr�rrr�rr .. ■EMErrrrrrrrrrrrrrMIrrErrE■ Now ■r�r��■ ■ENOMONrrmrrmommo■ ,... MENNENrerrrrrrrerr�rrommoo .. ■rMrrrrrrrrroerrrrMrwrrrr■ .. ■rMEwrrrrrrrror�rrrMIrrreEM■ ..- ■,�r��esrrONE .. - ■�r�r�rrrrrrrrrrr�rr�e��r�e �rrrrrMEMEME■ Installing Company Name � a Q� �, n, -,rChec* or= Certify t _D:�i C & kWss Te!ephone _ PMWCo. Nameof i km'tber . WSUPANCE ZOVEPJW= I hm a parent labile o mr or its w owivalent which mks the � of MGL Ch. 14L Yes �[ � )� M Phase nKbcate the type coverage by king the appropriate box. A Itabrlrty b u Ance policy �j other type of indam;ty p gam G OWNEIM DISJRANCE WAIVED I am aware that the licensee by1does not ha�re the ' Ct of the Mass. General Laws. and that my s on this insurance d tai wanes this leqwWSW e of Owner or Owners Agem Owner r Check one: Agent h8 ft certify Ilial W of the deceits and Wom aticn 1 cans the best of my Wowiedge and that ap plrnroft work and orstal Q1 above action are true and accume to oe in aor arroe with an pertinent provisions at the � urr0er the pennt.issued fortlus apobcation wbl WKS IQ of me General taws. ctPkvnbw Type of Lxerree k4au, .lOtrrlleynlan L i I� z z - 0 A o; z a oa a A A 2 A 0 w A > A V 7 r A O Z w. p 71 i = 33 3� ~ A O w A O � Z G r die s Z O ti ORTN 0 0 CHU This certifies that has permission to perform .... Date ...... / ........ TOWN OF NORTH ANDOVER wiring in the,building of ......M!-! a .....M-! a t /tZi.� 7 5Z /,.. � Fee... .... R ...... Lic. No.,,V Check, It - eq37— 5546 PERMIT FOR WIRING . .................. ............... ................................................ .............. Mass. Commonwealth of Massachusetts Official Use 0111 . Department of Fire ervices Permit no. Occupancy and Fee Checked BOARD OF FIRE PREVENT N REGULATIONS [Rev. 11/991 (leaveblank) APPLICATION FOR PERMIT T PERFORM ELECTRICAL WORK All work to he performed in accordance with the Massa usetts Electrical Code (MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date • 1. 16.2005 City or Town of North Andover To thec�re rYb befow. By this application the undersigned gives notice of his or her inten 'o to perform electric r esc Location (Street & Number) 105 Autran Ave Owner or Tenant Nola Owner's Address 105 Autran Ave Imrie North Andover Ma Is this permit in conjunction with a building permit? Purpose of Building residential Existing Service Amps I Overhead New Service Amps / Overhead Number of Feeders and Ampacity Telephone No. 91 - 01845 Yes ❑14o [XI (Check Appropriate Box) Utility Authorization No. ❑ Undgrd ❑ No of Meters ❑ Undgrd ❑ No of Meters Location and Nature of Proposed Electrical Work: install: ded. ct in KIT for Micro, disposal and DW; inst. recpt for LV ltg. transformer, inst. SW/SW in KIT for ceil. Its. & LV Its. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ]In -No of Emergency Lighting grnd. 1:1rnd ❑ Batte Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS No. of Zones 4 No. of Switches 2 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges I No of Air Cond. No of Alerting Devices No. of Waste Disposers I Heat Pump Number TonsNo. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers1 Space/Area Heating KW Local Municipal Other ❑ Connection ❑ No. of Dryers Heating Applicances KW Securityy Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices of Equivalent No. of Hydromassage Bathtubs No of Motors Total HP Telecommunications Wiring: No. of Devices of Equivalent OTHER: ROUGH INSPECTION FINISH INSPECTION Attach additional detail if desired, or as required by the Inspector of Wires. 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 suc�verage is in force. and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F_J BOND ❑ OTHER (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion I certify, under the pains and penalties of pejr ury, that the information on this application is true and complete. FIRM NAME power Wiring & Emergency Response, Inc. LIC. NO.: A17354 Licensee: Stephen Decker Signature LIC. NO.: (If applicable enter "exempt" in the license number line) Bus. Tel. No.: 1-800-418-3221 Address: 44 Stedman St, Unit 2, Lowell, MA 01851 Alt. Tel. No: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabi i insurance cov a normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) o owner's a Owner/Agent IPERMIT FEE 70.00 0 4K S CHUS Date. 4 ..... ... .... ... .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ :.7— .. .................... has permission to perform 4A"P- - ..................................................................... wiring in the building of .... �Z� ............... ....................................... . ............ .. ..... at . P< "-j ......................................................... . NorthAmdover, Mass. Fee—. ... ...... Lic. NO,4 .. (—) ..... ......... (. . ............................ ELECTRICAL INSPECTOR Check # 6410 u� Commonwealth of Massachusetts Common ea "�= = Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 6' yl0 Occupancy and Fee Checked,35" I[Rev. 9.1051 (lea,e blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All ssork to be performed in accordance \sith the khissachusetts [:Iectrical Code (%I :C) 5)7 CMR 12.00 (PLE�I.SE PRINT IN INK OR TYPE ,4LL INFORA,L•1 TION) Date: L/-- City or Town of: /VOIPIW &%AV To the Inshecin of'YVires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) lo,�— _ Owner or Tenant pie Telephone No. 7?,T' T7f /<Z>S— Owner's Address i6S— /174t -422M6 / Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building [���'��' Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: %ys Ge%l1'7071 s"2!9 2 cu z 4er /N 6��eex,6;r___ Con 1etion tv the M/lowine table nury be waived by the hispec•!or of II%res. I Mach additional detail i/desired, or as required by the Inspector of II ires•. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CIIECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certifj;, under the pains and penalties of perjury, that the information on this application is trite and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (!/'applicable, enter "e.�empt" in the license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Security System Contractor License required for this work, if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes not have the liability insurance coverage normally required bylaw. B y si mature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Own tura nt V 7Tp 7;,5,/9r!;—.,FPER�>L11T FEE: (S 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 AboveIn- Swimming Pool rnd. ❑ rnd. 0 o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. Detection and No. of Switches No. of Gas Burners InitiatingDevices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices Heat Pump Tons KW No. of Self -Contained No. of Waste Dis osers P Totals: I.Number Detect ion/Ale rtin Devices No. of Dishwashers Space/Area Heating KW Local ❑ MunicMun'cipal chon El Other No. of Dryers Heating Appliances KW SecuritNo. 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: I Mach additional detail i/desired, or as required by the Inspector of II ires•. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CIIECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certifj;, under the pains and penalties of perjury, that the information on this application is trite and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (!/'applicable, enter "e.�empt" in the license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Security System Contractor License required for this work, if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes not have the liability insurance coverage normally required bylaw. B y si mature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Own tura nt V 7Tp 7;,5,/9r!;—.,FPER�>L11T FEE: (S Signature Telephone No.