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Home My WebLink AboutMiscellaneous - 125 SAW MILL ROAD 4/30/2018 / 125 SAW MILL ROAD 210/104.6-0105-0000.0 i Cunningham Lindsey U.S.,Inc. P.O.Box 703689 Cunnln ham wDallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 / CLCAT@CL-NA.COM ***********************AUTO'*3-DIGIT 018 781 T3 P1 95000058971 Building Commissioner or hNInspector of Buildings 120 MAIN STREET N Andover,MA 01845 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 2263171 Policy Number: 2263171 11 co Company Name: MERRIMACK MUTUAL FIRE INS Cause of Loss: ICE DAM LO Date of Loss: 2/1/2015 a Insured: Edward &Judith Silva Property Location: 125 Sawmill Rd. Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 36: No insurer shall pay any claims (1) covering the loss, damage, or destructions.ta a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. 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. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 I 95u6 Date..................e................ t t NORTH 1 o?;•,�`"-;• "�O� TOWN OF NORTH ANDOVER PERMIT FOR WIRING n This certifies that ................... . .. .. .:U ?.a......................................................... haspermission to perform ........,��cG.� ................ _. C wiring in the building of...........�?.�L/tw.................................................. I at....1 ...... ................... .. ,North Andover,Mass. Fee.... .. Lic.No.�.(rC .. ..... �... Gc� X9(4�fAL INSPEC�OR Check k Official Use Only (mom.:wruueaCCh o��/Ja.�lachulsC�i /�/,s• f,, . Q c7 Permit No. a Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS i 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 INVORMATION) Date: 49 City or Town of: ,()nLa /&I ��,� To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) �5' 4kr& Owner or Tenant &2AA5 S&J Telephone; No. . Owner's Address 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 f Location and Nature of Proposed Electrical Work: 3 -� �l Q /r^> Or, �cu r'� c�STe,kj Completion„f thtable may be waived by the Inspector otWires. -- No. of' Total .y No. of Rec'_;sed Luminaires No_ of Ceil.-Susp.(Paddle)Fans Transformers Kl/A No. of Lia'air.aire Outlets tNo. of Hot Tubs Generators KVA Above In- 1 0. o smerger. y :g tang No. o`Luminaires S,vimming Pool arnd. ❑ grnd. ❑ Batter, Units . No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of.Zones No. of Detection and No. of Switches No. of Gas Burners I .'t.=rtinz De. ices Tot:cl No, of ederting Devices No. of Ranbes No. of Air Cond. 5 No. " I- eat P_-mp Nt I, bet Tons KW No. of Sel untamed -. No. of V,'aste Disposers _.........._. __ p i:-ots�:;: '' �. DetectiontAlertin?Devices —''— 'Municipal No. of Dishwashers Spir_-e/Area Heating KW Local ❑ Connection ❑ Other Heating Appliances KW Security System: : No. of Dryers b no.of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. romassa H doe Bathtubs No. of Motors Total HP Telecommunications !firing: y G No. of Devices or Equivalent OTH ER: Attach additional detail if desired, or as required by the Inspector of ffli es. Estimated Value of Electrical Work: (When required by municipal policy.) DD Work to Start: inspecti ns 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"covera(le or its substantial equivalent. The undersigned certifies that such coverage is in force; and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury, that the information On this application is Irtre acrd Complete- FIRM NAME: �� '/ LIC. NO.: J�e. Licensee: Zk_17-�Ure /2/'C2 ' Signatur LIC. N002_;4,D (If applicable, enter "exempt"in the license number line.) Bus.Tel. INo.:ID03 S 44 Address: _ `�'L�a� �� d/�<S D�O�� Alt.Tel. No.: *Per M.G.L. c. 14 , s. 57-61, security work requires Department of Public Safety `'S" License: Lic.No. SCG OUO s/7 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does nor have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑owner's age t. Owner/Agent I PERMIT FEE': . S, Signature __ — Telephone No'. _ f t i I COMMONWEALTH OF MASSACHUSETTS r)t:: r_rT-Plrtnntc 1J REGISTERED SYSTEM TECHNICI N ISSUES THIS UCENSE TO ARTHUR W PIERCE A 1 UPHAM .T G SALEM MR :.1�197o.-2516 \� r I c 10"ci D 07/31/10-_ 320257' - 1(l�� (' �'!I:/•1,1'�i}' '71--��( -tea �.( '{'^•S _ - (b a. _• 1 y Certificate o(Clearance rF Number: SS irC 000517 I�•`; ; Expires:'D5130.!301D Tr. no: 152.0 y S-License: w jT SECURITY SERVICES ARTHUR Vv PIERCE 1 B CLINTON DR M =:vLLIS. N.-, 03049 Ji /i /i✓ (� Commissioner / DIG SA E CALL CENTER:ER: (BBB) 344-7233 r J 1 Location tSA W ►t+ �� R No. a Date 'Q NORTH TOWN OF NORTH ANDOVER 3: OL Certificate of Occupancy $ cNu9 <� Buildin /Frame Permit Fee $ s� st Foundation Permit Fee $ j Other Permit Fee $ Sio�lr ' �— TOTAL $ —� Check # 5 0 Building Inspector .1 TON" OF 1! i BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR.DEMOLISH HANE OR TWO FAMILYDWELLING WffiDING PERMIT NUNMER' DATE N SUM -) 0C -IGNATURE. C Building Commissioner/Inspector of Buildings Date ECTION 1-SITE WORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ND C y ,OU _M,q Map Number Parcel Number � 1J 1" . �1 , �j 1.3 Zoning Infonnation: 14 Property Dirt ensioas:, ff. inin Distnd....,. P{ 4SeCi'=LJse iot:�lrea - Fronta"e It 6 BUILDING SETBACKS ft Front Pard Side bard Rear Yard Required Provide R red Provided R red Provided 115. Flood Zone Infomution Water Supply MGI-C.40. 54) t 8 Sewciage Dnposal�Syst¢m'� , ilic . ❑ Private ❑ Zone Outside Flood Zone a Municipal ❑ On Site Disposal System-IJ :CTION 2--PROPERTY OWNER SIP/AUTHORIZED,AGENT Owner of kecord :�tiJ fl f`D } . �c��i� AID qe(I't-int�)- Address for Service: �. 0)$ti4- \ nture Telephone C� Owner of Record: lame Print Address for Service: z aature Telephone hone CTION 3-CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ ,nsed Construction Supervisor: License Number .ress .. :' Expiration Date ature. Telephone ®0 rum tegistered Home Improvement Contractor Not Applicable ❑ pany Name Registration Number ess SEEM Expiration Date ,ture Telephone SECTION 4-WORKERS COMPENSATION (NLG.Ir: C 1'52 § 250) 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 buildin rmit. Si ned affidavit Attached Yes :..0 , No,,.. .0_; SECTION 5 Descri tib of Pro' osed.Work check abl a, ticable New Construction 0 Existing Building 0 Repair(s) ❑ Alterations(s) a Addition ❑ Accessory Bldg. 0 Demolition. ❑ Other 0 Specify Brief Description of Proposed Work: SECTION 6 ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollar)to be Com feted by permit a licant 1. BuildingO a 'Building Peimtt Fee c Multi;tier' ; 2 Electrical .(b) Estimated Total-Cost of Construction 3 ._Plumbing'.. ..B.uilding.Permit fee(a) (b). 4" Mechanical,(HVt1C . ;• 5 Fire.Protiecti- n, 6 . Total 1+2+3+4+5 ..... Check'l��urfi'ber. SECTION 7a OWNER AUTHORIZATION TO BE COMPLETEb WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. rbelid ner Date WNER/AUTHORIZED AGENT DECLARATION ,as Owner/Authorized Agent of subject at the statements and information on the foregoing application are true and accurate,to the best of my knowledge Print Name 1 ! a Si ature of Owr►er/A en Date f NO. OF STORIES SIZE BASEMENT OR SLAB { SIZE OF FLOOR TRABERS 1sT 2 3 -_ SPAN r DIMENSIONS OF.SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X [ TERIAL OF CHIMNEY UILDING ON SOLID OR FILLED LAN)'V I!SBUILDING CONNECTED TO NATURAL,GAS LINE WOOD STOVE INSTALLA ION CHECKLIST f' �p}��'X Permit A building permit is required for the installation of any solid Juel burning appliance. The building permit and installation i pection are limited to the stove installation and not to the stove construction. ( Stove A, New Used, B. Type/radiant 01201_-r"j, ' Circulating C. Manufacturer L-03'T 5 XO',V_Lab. No. j Name/Model No. L-or r - Ar15wL*- —Collar size 6 " Dimensions/Height 73 sld`^� _ 9.03f�► 11 . 16'fYD I_sngth Width Chimney A. New _Existing B. Size(flue area) C. Other appliances attached to flue(Number and flue size) ...__� D. Prefab(Manufactur name and type) E. Masonry/Lined _ _.Flueliner._ - type h manulactur r) F. Height(refer to diagrams) cap OVER ICr I I I IZtt Ir11t1. 2'MIP) Z "1!rt. 3 MIS to :�_I�j'II 3 ;,11ct. I \, UIN. Igtr MIN. �Licy7ylG':1 n x HEARTH CHIMNEY HEIGHT Hearth(non-combustible) A. Materials I B. Sub-floor construction C. Minimum dimensions(refer to diagram) Clearances and Wall Protection(see stove in=tallation clearances chart) A. Type of wall protection provided B. Clearances(refer to diagrams) r FIREPLACE con!"IER WALL/CEN TTER Np R T!y Town of E ^M Andover 0 0 O� aCLA dover, Mass., CICADRATED P?gcv �C7 S H E` BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D IVABUILDING INSPECTOR THIS CERTIFIES THAT �W/�� .. ......... ............ ................................................................................................ Foundation c n ' has permission to�ere�ct'...�.N...�S........�.�......... buildings on �� Jew m1f I� I d.......... Rough �� ...................................................................... to be occupied as . ... ............ .....................................' .......................................................... Chimney m ... . .......... provided that the person accepting this permit shall in every respect,conform to the terms of the 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. /1p y a//�s- �� Rough PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. g PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS 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. NORTII Town of And ' O .w.w•, .�F'. � • o coc"= I't _T'0 ' dover, Mass., 7� 0RATE0 pP �W H ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System .......��... ........... BUILDING INSPECTOR THIS CERTIFIES THAT......�.( WA 10..........4��..!fvA..................................................................................... Foundation 1� has permission to�erect'...�.N. ........�.�......... buildings on .......� ....sib-w............. ....IJ.....................�.......... Rough to be occupied as I �� V�— Chimney ...................................... ................ ,7.......................................................................................................... provided that the person accepting this permit shall in every respect,conform to the terms of the 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. /!9 y S//C*,5_ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS CRough C"O." ...... ................................................ 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. Smoke Det. SEE REVERSE SIDE 0::tea Ust On The Commonwealth o Massachusetts f � Dcpar:mcnf of Public Safc;y ' occursmy Z. Fet Q+ecke! BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12= 3/90 (tt,.t blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be periormcd In accordance With the Ma"aehuscru Electrical Code.. 517 CMR 1200 (PLEASE PRINT IN I2iF OR TYPE ALL INFORMATION) Date 115— I _? -016 City or Tot.rn of ./U- /� �_ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Circuit 06rcr or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization 110. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service Asps / Volts Overhead ❑ Undgrd❑ No. of Meters Number of Feedcrs and Ampacity Location and nature of Proposed Electrical Work LOt'7 VOLTAGE ALARsl SYSTEM No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA Above In- No. of Lighting Fixtures Swimming Pool grnd. ❑ grnd. ❑ Generators F.'VA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting NBatte Units No. of Switch 0,atIcts No. of Ca.. Purners �=TRr ?Ltp�S No, of Tones No. of Ranges No. of Air Cond. Tons No. of Detection and Initiating Devices No. of Disposals No. of Heat Total Total No, of Sounding Devices p s Tons KW s No. of Dishwashers Space/Arca Heating }0.1 No. of Self Contained Detection/Sounding Devices No. ofers Heating Devices KW Local❑ ilunicipal [:]Other >hy g. Connection No. of Nater Heaters KW No, of o. of Low Volta Burglar Fire Si ns Ballasts n Card Access CCTV No. Hydro Massage Tubs No. of Motors Total HP ``� OTHER: JUN ? >`j 1987 INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES(D NO (J I have submitted valid proof of sane to this office. YES❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE X❑ BOND ❑ OTHER ❑ (Please Specify) Royal Insurance Company 10/8/96 Expiration ate Estinated Value of Electrical Work S � Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIR11 tIA9L Security Systems, Inc. d/b/a Sentry PrW-ective Systems LIC. NO. 1109 C Licensee James W. Lees Signatur C. NO.000080 Public Address 110 Florence Street, Malden, MA 021 Bus. Tel. No.- 617-388-9700 a ety Alt. Tel. No. 800-445-4505 O1.TIER'S lliS�nANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) � 00 Telephone No. PERMIT FEE S3./t 1JW 1,t1IMVIIAV"reliUn Ur iVAtUXxna.av ua a,3 DEDUUIi WOFPUNKSUM i0ARDOFFIREP�EMVR NRTXX1lA1101VMR7C1lr1R1ZiW Permit No. / 1,s• Occupancy&Fees Checked APPLICATION FOR PERMIT'TO PERFORM ELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS RINMICTRK:AL CODE,527 CMR 12:00 _ J(PLEASE PT IN INK OR TYPE ALL INFORMAnON) Dat p Town of North Andover To th Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below, Location(Street&Number) Owner or Tenant Owner's Address Is this permit in conjunction with a bug permit: yes No (Check Appropriate Box) Purpose of Building / ' ?�� Utility A ration No. - Existing Service _zoo Amps1?Volts Overhead M Underground rM No.of Meters ' New Service Amp%.../ volts Overhead Underground C3 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work JACP No.of Lighting Outlets No.of Hot Tubs No.of Tranaforrnea Tout No.of Lighting Fixtures Swimming Pooh Above Below Generators KFA uWrl KVA No.of Receptacle Outlets No.of OU Burners No.of agency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS Tons No.of Zones No.of Disposals No.f Hest Totat TOW No.of Detection and Pumps Tons KwInitiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained No.of Detection/Sounding Devices � Heating Device KW Load Municipal � No.of Water Heaters KW No.f No.of Connes4ona Si Bailatis No.Hydro Massage Tubs No.of Motors Total HP OTHER• bA=xeCo�Hr�ntrblherac}i�er efM�du�Ga1®1I8Ws IhmeaanetI�atdtylismtael�icyirrJUdrR(7m ase vaist YES I�gstthmledvaidp�ofNO saate dle0>)iz Yf;s � ffywha<eclrad®dYFiS,p�hka tm of by INSURANCE oUR a ,) v17 L / WodcbSm hpeWonDiMgqz*dRail EftftdValredEkCWcWWadc$ %nadFtr>aJtiescfpmjtj; Fold fINNAME ( i LimmNoL ice_ �,O b ,IV, Lioer=& Addkes6 CA &,14, b TeLNa RaT770 0 73 OWNR'S INSURANMWAVIR-JamzmR#U16Li=WdMmt bin== aril AkTdNa .�dretmy9grl�urndiepaariappicationvi�esdinragomrrrnt °°`g'� ��b�rrialegtival�tffiregialed�' �GaletAlLawa (Please check one) Owner Agent Telephone NO. f PERMIT FEE S U �-��/��' ® � S -- 2- � ,� a:� lam'D� S `� �� : ". .............. Date......... .........< NORTH "� TOWN OF NORTH ANDOVER _ PERMIT FOR WIRING SSS,RcHUS �a This certifies that .........�....... ...................... .. .......�!f...............�::......... 9 has permission to pefform wiring in the building of.. ..... ...................... y at.. I..t.!....G�..0.......< � ,North Andover,Mass. Fee.,5 ......... Lic �/.— .1! ELECTRICAL INSPECTOR Check # d(/ 5/ b9 TK'. . .Y..� �� ;�' 1 Date. of 40R,e ,ti TOWN OF NORTH ANDOVER ' 3r PERMIT FOR INSTALLATION t • 1 • Oqq.u.-..w�... �' I SACHUS This certifies that . . . c K R �� . s T N c has permission for installation . . A R.,m . . .S 5.kwi r. . . in the buildings of . . . . . .i. . . at . . . .o.tr. . .S.r'.4!^!. . . �� (� � rth Ar ass. Fee. .Gw. Lic. No. ./.d?(. . . . . . . . . . ` 7d{ IyCAB'�JSP CTOR WHITE:Applicant ANAR Building Dept. PINK:Treasurer GOLD:File w IJW L UiV lvlv[v rrr1a...L3 yr[rJtLaYit,[1v.7I.s lV DEPARMWOFPUBUCSAFETY Permit No. BOARDOFFMPREVEMON7.Z CM120 Occupancy&Fees Checked A PPLICATION FOR PERMIT TO PELECTRICAL WOT3 IV ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSAC SSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat � /05— Town of North Andover \ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work de bed below. Location(Street&Number) Owner or Tenant Owner's Address �B„✓1 Is this permit in conjunction with a building permi t: Yes a No � (Check Appropriate Box) ��//�� Purpose of Building J l to! Utility A zation NomLgL Existing Service Amps &Lj-4Volts Overhead 0 Underground No.of Meters ' New Service Amps olts Overhead r'ml Underground ED No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swinuning Pool Above Below Generators KVA ground El around ri No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposal No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Ate&Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices _ No.of Dryers Heating Devices KW Local Municipal Other - Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER• ', ><�aartoeCcne�Pli�nttblhett�gtnart�ofMat�dz�GattzelLa♦vs IhmataaeiIiabdtyhaatoefb6cyirr]udrgCamplele orit4sub�tr6alegtivalalt YES NO IhafesuhrnilkdvafdptccfafW= t roffm YM ffyutha�et�edaedYES,p�itdt ledrt5Fof by o nvsvRAr>CE anIEx E#WmDale FsWi*dVall c(&cblcd Wc&$ WC&ID&att hapecirnDoReqRao Pill Sigledundar&l sofpgjW.. R MNAM-E- L;oemerra 3 3 Licome �/ �+®��iv, �..1 U{O.Q Sigmhie IloaseNo 5 C4 f C Adim it Q A' ALTdNa OWI WSMRANC£WAM3kIaTnawae Liorxw&mnotha etheir atneoo�,>getxitssib�lialec}av�Ja�t�Lac}modby,M h G alL vs artddamysi Awcnftptx<i*pimbmwai%eslFimlo# nait (Please check one) Owner ID Agent Telephone No. pERWr FEE$ signature Owner