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HomeMy WebLinkAboutMiscellaneous - 11 LITTLE ROAD 4/30/2018 11 LITTLE ROAD ��� _210/016.=00.0 � � ._ -- ----- -�--- - - - - -_J • J Location /r k' �;. No, Date ,.oR,►, -TOWN OF NORTH ANDOVER Jf : of M tAwo s • Certificate of Occupancy $ ;�s'•^�Eta Building/Frame Permit Fee $ �. Foundation Permit Fee $ �w Other Permit Fee $ is TOTAL $ i ' f Check #2 186U1 \ €' Building Inspector/ TOWN OF NORTH ANDOVER ` BUILDING DEPARTMENT APPLICATION TO CONSTRUCT WA5 RENOVAT1.6 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED. SIGNATURE: Building Commissioner r of Buildings Date ,7- 7 SECTION 1-SITE INFORMATION • _ O 1..1 Property Address: / drrens: `/-fin//J 1.2 .Assessors Map and Parcel Number: / A, �O V(,4 t A, ^ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required I Provided Required Provided 0 1.7 Water Supply M G L.C.40. 54) 1.5. Food Zone Infomvtion: 1.8 Sewerage Disposal System: Public 0 Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No M 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 4- 9TT- 2.2 Owner of Record: Name Print Address for Service: Y Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. 0✓l.F� ��V \ 7 � l/do L C T^ y�Lf� License Numberwn Adore ZX-15 C) Expire on D# rgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 C16/"J -2- Company Company Name / �O J m Ad ��' /�oO / �^ p-� ✓ Registration Number r �l (� .(�f !� J U L � r ,a r � g^ Q �D Z f� / yYi-5—D E � Signature Telephone G I SECTION 4-WORKERS COMPENSATION(M:G.L C 152 § 25c(6) , 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 permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterati sj, ❑rWa Addition ❑ 1 S . Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: y CiOW L� lJ` Gc�spt'o o le/ SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be bFF1CIALUSE UN . + kms"k Ys,'r➢ ^m Completed b permit applicant rt � R"_ 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection �� 6 Total 1+2+3+4+5 pco Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby au *'z ze to act on My behalf,in all m�'atters.rel.-„atirve to work authorized by this building permit application. Signature of Owner - Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION h ``~ ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print N71 cK O / Si tore of Owner/Agent 4te ti NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 ST 2 ND 3 SPAN DIMENSIONS OF SILLS DIlvIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHD&EY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE • ��°TM�" RECEIVED Town of North Andove��, # Q, r OFFICE Office of the Planning Depai elnt� `' S r Community Development and ServINsS Ai8h12: 24 'Ss�cKust� 400 Osgood Street North Andover, Massachusetts 01845 TOWN OF htW://www.towinofiiorthandover ANDOO .!F? Lincoln Daley ASSACHUSE? NORTH Town of 4Andover 0 . ..w 41 1�! C% - C A E - dover, Mass., • T COCHICHEMCK y� �qs RATED PPG,c�� �i BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.............. ............................ Foundation has permission to erect........................................ buildings on .../...... Rough to be occupied a __�........ ... Chimney provided that the person acc ing this permit s I in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes a By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION S � T ELECTRICAL INSPECTOR �"� Rough ..................................:.............................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the rovision of MGL c 40 S 54, a condition of Building Permit at: // Li' s t is that the debris resulting from this work shall be disposed of in a prop 'licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: lvct 1- 4/004 fRoelrs�;.'Y )3�0(�V—ty S';0'1&Vt �i (Location of Facility) Signature of Peoit Applicant Fire Department Sign off. Dumpster Permit Date Or asal PAR MOUNT VINYL SIDING & CARPENTRY 7 School Street ' MA LIC#056858 Methuen, MA 01844 Reg#108659 (978) 794-9950 PROPOSALS MITTED TO P. ONE DATE 4L, IV 7415 STREET 9 ` % / rJOB NAME +rr�t�V CITY, STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF,PLANS JOB PHONE We hereby submit specifications and estimates for: J ��' ! r _ .• 0 4t t4l) 77,�t,_P L L'% �`/11 i✓. r.l1;i% rC/'ja� r._� V-/_1VW_ ON 191-L It shall be the obligation of the contractor to obtain all permits as the owner's agent;owners who secure their own construction-related permits or deal with unregistered contractors will be excluded from access to the guaranty fund. „ Payment to be made as follows: dollars($ � All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifica Authorized Je- tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents _1Aor delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. LeAcce nr>e at 11rnpnsal—The above prices, specifications DO NOT SIGN THIS CONTRACT IF are satisfactory and are hereby accepted. You are authorized THER �AR ANY SPACES as specified,Pay ent wiII made as outlined above. ance: �� t �s Signature Proposal dD PARAMOUNT tri "VINYL SIDING & CARPENTRY 7 School Street MA LIC#056858 r (� Methuen, MA 01844 Reg#108659 , c (978) 794-9950 PROPO BMITTED T PHONE DATE L SUr STREET. JOB NAME CITY, STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF:PLANS JOB PHONE We hereby submit specifications and estimates for: > }tlf'7`y � -- � ,'l 7. `� LIQ-k119_T1 CJo // C � '�f ✓`�Z��"��.�.1�' % rS It shall be the obligation of the contractor to obtain all permits as the owner's agent;owners who secure their own construction-related permits or deal with unregistered contractors will be excluded from access to the guaranty fund. dollars($ Payment to be made as follows: ). All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifica Authorized 1 �- tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents / or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. L atwit Af frapsid—The above prices, specifications DO NOT SIGN THIS CONTRACT IF ns are satisfactory and are hereby accepted. You are authorized THERE ARE ANY BL NKAMES rk as specified.Payme t will be ade as of lined above. ptance: } �- `=� Signature The Commonwealth of Massachusetts I Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 \" www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ^(f�f/V / n ��C.�•4� Z Address: ��C;�4��� r> T— �/Il� /rLaey,-1 III City/State/Zip: /11 c0(_A6/M /L/O 0 C�7 `� Phone #: .9 ?g^ "_7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. El am a general contractor and 1 6. E]New construction employees(full and/orart-time .* have hired the sub-contractors p ) 7. ❑ Remodeling 21M am a sole proprietor or partner- listed on the attached sheet. # 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 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can 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 DIA for insurance coverage verification. I do hereby cer y u der the#ftns penalties of perjury that the information provided ab ve is tru and correct. Si nature: Date: �_ 0 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A 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. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit 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 and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia Location �•� No. � r Date 10 �0 TM TOWN OF NORTH ANDOVER Certificate of Occupancy $ s° f Building/Frame Permit Fee $ ��s Eta Foundation Permit Fee $ s.4cNus Other Permit Fee $ Sewer Connection Fee $ t Water Connection Fee $ TOTAL $ uilding Inspector 06/27196 t19s ( 5.OUPAID • - +7 8 72 Div. Public Works PERMIT No. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE w MAP 1-40.©` LOT NO. (76/0 2 RECORD OF OWNERSHIP PATE BOOK :PAGE ZONE I SUB DIV. LOT NO. LOCATION /� —e�j � PURPOSE OF BUILDING OWNER'S NAME/ �) NO. OF STORIES /C g,IQZ•/E/ a�— SA OWNER'S ADDRESS f» BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME e�f/% SPAN DISTANCE TO NEAREST BUILDING _ DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES —SIDES REAR GIRDERS I AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDIIyG NEW SIZE OF FOOTING- X a, IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQU REMENT F CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING.CONNECTED TO NATURAL GAS LINE 1 INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST . - SEE BOTH BIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SC. FT. PAGE 2 FILL OUT SECTION$ 1 - 12 - EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY S ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVE BY BUILDING INSPECTOR DATE FILED ■UILDING INSP[CTO/ SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE , `OWNERTEL.x PERMIT GRANTED CONTR.TEL r / CONTR.LIC.N z HICK BUILDING RECORD 1 t OCCUPANCY 12 _ WGLE FAMILY S'OPI S THIS SECTION MUST SHOW EXACT.DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OfFICESLOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED: THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION _ B INTERIOR FINISH CONCRETE CONCRETE BL K. PINE BRICK OR STONE HAROW O _— PIERSPIASTER I _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA _ FIN. ATTIC;AREA N_O B M-T FIRE PLACES _ HEAD ROOM _ MODERN KITCHEN 4 WALLS I 9 FLOORS - I CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARD".-'D _ ASBESTOS SIDING COMMCN VERT. SIDING ;SPH. TILE STUCCO ON MASONRY _ 1 STUCCO ON FRAME I BRICK ONMASONFf ATTIC STRS. 6 FLOOR Ii BRICK ON FRAME CONC. OR CINDER BLK. ! STONE ON MASONRY WIRING i STONE ON FRAME II ADEO SUPEROTE I-I NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) _ GAMBRELMANSARD TOILET RM. 12 FIX.) FLAT 11 SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 6 GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOCR ' •– r_ TILE DADO - I g FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &—COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS - - - 7 NO. OF LOOMS It .. _ B'M'T 2nd I_ ELECTRIC . .. Ifl 13rd NO HEATING X0RTFj To"- of 0 dover No. 26 2 ►- Y klgtaf. rt dovery Mass., 19 COC.IICMEWICK ` ��DRATED 5F BOARD OF HEALTH PERMIT TFood/Kitchen a Septic System BUILDING INSPECTOR THISCERTIFIES THAT........................................ ...:.......................:............................... ............... Foundation has permission to erect....... ....... .:. .. .............. buildings on ......... ... ./....... .. - . .. ..... ..:: Rough �( .. ...:.......... t0be OCCUPI@d as....................................................................l.vV .�..�. ........'...�. ..(...�. ..................................... Chimney provided that the person accepting this permit shall in every respect confor0lo the terms o he application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .................................... . .. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. -OFFICES OF: _ TOwn of - - _� '_1Street' APPE.•ALS .�- =NORTH ANDOVER Ivonh Andover. BUILDING t ,e - Massdchusetts o I s4s CONSERVATION DM ISION OF HEALTH PI-14-NN G PLANNING & COMMUNITY DEVELOPMENT ' KARE-N H-P-NELSON,DIRECTOR 111 1G.^rC:1I1Ce with the �iC:S��.=5 .. •'vi`' _:,. S a co dlt.Cn of Building Permit Number s :`ct :ne_ det:is resulting firer this work shall be disncsed e[ .n s prene:i. -s:: sClid ;rsie _'�^osc. :ac. c:c:-.cd L' S s byMGL c i r i ne debris will be disposer' of in_ /001 cn ct GJ Stcnat::re Of crani ppiicant Date :TOTE: Demolition permit fro= the Tota of ',forth Andover must be obtained for this project through the Office of the Building Iaspector. i 1 . N2 Date......711 N- 1770 / HORTI{ °ft °;•_�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING •,,r.o.��`te o SSACMUS6 ti This certifies that ....!'►.A........4m...... ........................................ has permission to perform ...ter e..R..Jl �......... :fy ..........................93 wiring in the building of ......5�'+: !A ......................................... m at....t3........ ....... .................................... , ,North Andov asg Fee...1.,.-A)... Lic.No.d�. ......... ....... �.�...o ELECTRICAL INSPEcmlk C33f WHITE: Applicant CANARY: Building Dept. PINK:Treasurer - 7 he Common O AR O'Nee u,e only s�-- setts (//aJ Perntt b. ( 77 ' Department of Public Sa Iry BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 occupancy s Tee o,ecked (leave Dlank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO i All work to b-c performed In accordance with the Macsaehusetu Electrical Code, 527 CMtZ7 RK (PLEASE PRINT IN INK OR TYPE ALL INFOMATION) Date City or Town of A)6 AV����� To the Inspec orThe undersigned applies £or a permit to perform the electrical Work described belLocation (Street & Number) e T Oc.•ner or Tenant O'wner's Address �. Is this pewit in conjunction with a building permit: Yes ❑ No ,11' (Check Appropriate Box) Purpose of Building f 'ce' Utility Authorization lip, Existing Service —lav Amps I z/// Z t/V Volts Overhead ❑Undgrd❑ I;o. of Heters �f ; New S`=rq�ce IOU Amps -10 / 2461 Volts Overhead ErIJdgrd ❑ 10, o° Peters Number of Feeders and Ampacity Location and Nature of Proposed Electrical ','orkSt'/1LlGC RpSt'/� AC No. of Lighting Outlets No. of Hot TubsNo. of Transfo n=rs Total KVA No. of Lighting Fixtures Swimaing Pool Above In- grnd. ❑ grnd, ❑ Generators kVA No. of Receptacle Outlets No. of Oil Burners INo. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALAILMS I;o. of Zones No. of flanges Total No. of Detection and No. of Air Cond. tons Initiating D:vices No. of Disposals No. of Neat Total Total r Puns Tons l No. of Soun_ing Devices No. of Dishwashers Space/Area Beating 11-W I{o. of Self Contained Detection/So-nding Devices r No. of Dryers Beating Devices K+,' Local 1:1Nr-'racipal nOther Connection'`] f No.o. of Waterer Heaters kJto'Fl ' oJ'O• of Low Voltage Si. ns Ballasts Wiring Ho. Hydro Hassa e Tubs > g Ito. of Motors Total HP OTHER: , L121�ce0 r1�� ee �? INSURANCE COVERAGE: Pursuant to the requirements of I•tassachusetts General La s I have a current Liability Insurance Policy including Completed Operations Covera-e o: its substantial equivalent. YES❑ NO ❑ I have submitted valid proof of care to this office. lTS[] NO [] If you have checked YES, please indicate the type of coverage by checking the appropriate box. IKSU-,',010E ❑ BOND ❑ OTHER ❑ (Please Specify) (54624>C&-W4--A Exp' anon Date) Estimated Value of Electrical 41or'r: S to S-,art `J�Co Inspection Date ecqu^_sted: I:oug,,. Sign-:td and-:!r tth-2 penalties of perjury: l� i(0. 139/ Licensee _Signature No d' zC address V �l B115 t.' /r✓' ��'' Alt. Tel. I;o. 23- O� 0l:�-RAS I('iSURANCE WAIVER: I am a'-'a---c that the Licensee does not Have the insuran:e co•rerage or its sub- stantial equivalent as required by Massachusetts General L s, and that Fly signature on this permit 1 application waives this requirement. O-.,•:jet• Agent (Please cheer. one) 1 y