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HomeMy WebLinkAboutMiscellaneous - 13 ROYAL CREST DRIVE 4/30/2018 �I?7 Ro��.Q Cre�r i BUILDING FiLt Date.....�AA.......... OF 40Rrh TOWN OF- NORTH ANDOVER ' PERMIT FOR WIRING ;,ssACMU5�S� � e} / This certifies Iha .... 61.... i.............�.........................: �° . has permission to perform '.! 25 ��.t'! L ^<3 �z �,5 e wiring in the building of. �' .................................... L% 11. S�' .,....""`''.. North Andover,Mass. tie.. ..." Lic.No. � 5 � !.. !?... .....�. ....... .......... �{�} ICAL INS y Check# 4O U i Commonwealth of Massachusetts Official Use Only Department ®f Fire Services Permit No. 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 (PLEA SE PRINTWINKORTYPE ALLINFORMATION) Date: Aur,U t ;(G , I L4 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 50 Q O U CLI C,f',L.-S.- 0 2 Owner or Tenant 4M►C 0 t46 rC]-h A N Dtiv<V- (2.. Telephone No. Owner's Address u i cb r1 13 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: C�eCK GI e 2 t r ( (bhn�C-F-►®�`S 11`1 80-5@ 6oz--ct etedn-; C. )-ko-+ Une VoI �6Lqe. 4-6trr-toStq- S qn& CtrC.o►k b(cele-rS F e- iriq -t-h-e-.S e 'u n 14 ' Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units t No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones i No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers HeatPump Number I Tons KW No.of Self-Contained Totals: "'""' """"......""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3®C) o O (When required by municipal policy.) d Vork to Start:8(a le I 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: 1NSURA=NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and enalties of,r�er�ury,that the information on this application is true and complete. FIRM NAME: D Aril i c r P, Vt kzd e- iFle-c-kW, LIC.NO.: Licensee:Dwi @ 1 PA V1 k-a 1 e— Signature o,,,,,. -X P LIC.NO.:3 16 50 E (If applicab e enter "exempt"in the license nacmber line.) Bus.Tel.No.: Address: t ® D R (C �� �.1�3cu K16-M m P- (5 a.L15 � Alt.Tel.No.:` *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 PERMIT FEE: $ i25 Signature Telephone No. The Commonwealth of Massachusetts . - Department of IndustrialAccld6its Office of Investigations IF 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Legibly Name(Business/Organization/Individual): Address: City/State/ZipA �Y���'G l�Wl 1A- Q0a�) Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. El Remodeling ship and'haveno 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 11.❑Plumbingrepairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. ('Homeowners who submit this affidavit indicating they aie doing 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. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r� Insurance Company Name:. .l- , q'J�y ro,V-) C Policy#or Self-ins.Lic.#: `JG�(�`��J CSU l ( �� ExpirationDate: l Job Site Address: S 6 CZ�t.�Cc I c-r'Cs �D r City/State/Zip: 14,h z,o aL r C3 1 f3 Q.S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 Inve.stigations of the DIA for insurance coverage verification. X do hereb Certo under the pains and penalties ofperjury that the information provided above is true and correct. Signature• -�� '\) Date: Fit U�t a I t g' Phone# not rite in this area to be completed b city or town official. - Official use only. Do o w p y ty .ff 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#: C.OMMONWEALTH OF MASSACHUSETTS 0 � BOARD ELE MRICIANS ISSUES` THE FOLLOWING LICENSE AS' A, REGISTE RE DI MASTER E.L//E�TRICIAN > DANIEL P V I TA LE:: f �Z 1,90 DA{ E "ST J t THAM MA 02451-3773 15795 q ^ 07/31/16 : 35001 . ......:: ........ .... COMMONWEALTH^OF MASSACHUSETTS j - BOARS O:1 ELECTRICIANS i ISSUES THE FOLLOWING LICENSE + `! AS A'REG JOURNEYMAN .;ELECTRICIAN �.. DAN::IEL P VITALE 190 DALE:>ST.. ,. co jy I U J � WALTHAM .:.:.MA 02451- _. 3773 .� 31850 E X: 07/3,1/16 35002 ') ��oo c,5Ce p0 CORC"O CERTIFICATE OF LIABILITY INSURANCE 7(MM/8D�26 )A14 THI.S'CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS C, ER11FICATE 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(ies) 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 conibr rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: LESLIE HANNON James O'Connell Insurance Agen PHONE (g78) 667-6150 FAX No: (978) 667-0587 572 Boston Rd ADDRESS: JIMINS@OCONNELLINS.COM Unit 7 INSURE S AFFORDING COVERAGE NAIC# Billerica, MA 01821 INSURER A:Merchants INSURED INSURER B:A.I.M. Insurance DANIEL P VITALE ELECTRIC INSURERC: 190 DALE ST INSURER D: WALTHAM, MA 02451 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YMLIMITS A GENERAL LIABILITY BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIALGENERALLIABILITY (Ea occurrence) $ 500.000 CLAIMS-MADE a OCCUR MED EXP(Arryone Person) $ 15,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GE N'LAGGREGATE LIMITAPPLIES PE R PRODUCTS-COMP/OPAGG $ 2,000,000 x— POLICY PRD LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY A UTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPS Y DAMAGE $ HIRED AUTOS _AUTOS wa UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC5006538012009 10/11/13 10/11/14 X WC T1 IMIT FR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EA EUTNE Y/N E.L.EACH ACCIDENi $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yyes describe under DES�RIPTIONOFOPE RATIONS below E.L.DISEASE-POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Rerrarks Schedule,if more space is regri red) ELECTRICAL WORK CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE L LESLIE HANNON ©1988-2010 A ORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Date.. .�?. .. .'�.. .. .G/CJ "OR 04 o= �' TOWN OF NORTH AN OV R PERMIT FOR GAS INSTALLATION 5 �,SSACHUSEtt This certifies that . . . . . . . . has permission for gas installation . .,v-.—. . ��. . . .. . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .`5. ... . . . . ! ., North Andover, Mass. Fee�1.0.. . Lic. No-. "'2°�.. . �� . �. GAS a SFECTOR Check# /,-S�7 Ti 54 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date- NORTH ANDOVER,MASSACHUSETTS l-/ Building Locations / ��S Y / CV Permit# Amount$ Owner's Name New❑ Renovation ❑ Replacement ❑ Plans Submitted El . Oup o a x x COD H w o c oo . z H Gv; x c7 v x z aH v a a Q CW7 H z zQz C"o a W c4 w q E .WT x Z LT. 0: d x 3 1SUB -BASEM ENT U BASEMENT . 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLO O R 6TH . FLOOR 7TH . FLOOR &T H . FLOOR (Print or typ ` n(1 / f Name dW 1�� (o I Check one: Certificate Installing Company ® Corp. Address � I � Panner. usmess I eiephone ® Firm/Co. Name of Licensed Plumber or Gas Fitter ��� <�� C [INSURANCE COVERAGE Check orre: have a current liability Insurance policy or it's substantial equivalent. Yes No you have checkedMes,please indicate the type coverage by checking the appropriate boxyiability insurance policy Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one:Owner �. Agent i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Signature o icensed Plumber Or Gas Fitter Title Plumber L`3 City/Town Gas Fitter License NumBer Master APPROVED(OFFICE USE ONLY) (�j,'JOurneyman i" wt The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 K'ashington Street Boston, MA 02111 'ki www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lecgdbly Name(Business/Organization/Individual): ��\I ll Address: �rr�tsi✓ City/State/Zip: 09,A1 f IM ✓� yl �p� Phone#: Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I i 6. New constructionemployees(full and/orPart-ime .* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working king for me in any capacity. workers comp.insurance. [No workers' comp.insurance S. 9• ❑Building addition p ❑ We are a corporation and its required.]q ] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 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 we have no insurance required.]t 12.❑Roof repairs q ] employees. [No workers' comp.insurance required.] 13.0 Other Amy arplicant that checks box#1 must also ull out Gae sectio^o=i0—s:^.ot:n�*-th irso_ t Homeowners who submit this affidavit indicating they are doing all work and then hire outside©ntractors 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: tiR 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Phone#: 2 Eonly. Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one):Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: 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 apartnxents 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 notbecause 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-contractors)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 applica-uon for the peramt or license is being.requested,not the 1-epartment 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 homeowner 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 Investieafions 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MAS.SAFE Fax# 617-72.7-7749 Revised 5-26-05 w-Aw-mass._gov/dia Date..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that Co ................................... welter has permission to perform .....5,C.................... gof......../?0,-ye A ....... wiring in the building kt............... NorthAndover,Mass. at........ 10 'es. . Fee..4;...::.r.�?+.. Lic.No.1410:75.7. .... .. ........ ELECTRICAL INSPECTOR Check # 7214 _ _ Commonwealth afAliassuchusetfs CJiftc.ial F)"'Only — Department of ,. Pert" it No. 7 00 rcctipTicyanti lAcc C'heckccd BOARD OF FIRE.PREVENTION REGULATION (keel.9/0 I - leave:blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Ail Nvork lobe perfu itic d in acccrdimue with the Massachusetts Electrical Code(MEC),),527 C IR'12.00 (PLEASE- PP.:I!'4'TlrNA—K OR ITPFS LL1 7,-OX41ATI£.?v} Date. February 12, 2007 City or Town of; North Andover 7o the Inspector of Wires. lay this application the undersigned gives notice of his or her intention to periarm the electrical work described bclo�v. Location(street&Number) 50 Royal Crest Drive Building #13 _ Over or Tenant Royal Crest Apartments _ Fe-lephotte No, 978 686-7311 OwneCs Address .0 Royal Crest Drive. Noah Andover, MA 01845 Is this permit in conjunction with a.building permit? Yes ❑ leo X❑ (Cheek Appropriate Box) Purpose of Building ApartMentBlffldinn IJtilady Authorization No. Eadsting Service Amps l Volts Overhead❑ Undgrd❑ No.of Meters Neer Service Amps' 1 Volts Hrerbead❑ llndgrd ❑ No.of Meters - Number of Feeders and Ampacity - Location and Nature of Propose-d Electrical NVork: Emergency call - Main Breaker Change Corn lelion of the oliovvin F table may he waived by the fr,ire ctor of'lr:ires. No.of Total' No.of Recessed Luminaires No.of Ceil.Susp.(Paddle)Fans Transformers, k "fi No.of Luminaire OutletsNo.:of Hot Tubs Generators KVA No., f Luminaires Swimming Pool Above ❑ In- o.o ,mergencl ,agtg rizid, grnd. Battery Units No.of Receptacle Outlets No.of O l.Burners . FIRE ALARMS No,of Zones. No.of Switches No.of Gas Burners No.of detection and lultiatiog Devices No.of Ranges Na,of Air Cond'. Iota No.of Alerting Devices Tons No.of Waste Disposers lie-atPump Number ons V No.of Self-Contained Totals:,. it etection/AlertinDevices u cig3il No.of Dishwashers Space/Area Heating KLV lAcal El�3 ❑ Mier Connection. No.of Dryers .Beating Appliances Kms' Security S}•steins.* No.of Devices or E uival€ut No.of Wa-Te—r No.:of. No.of _ KW No.: Heaters signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total:HP a ecommunicattonsWiring: s No.of Devices or Equivalent. OTHER I ' Attach additional dciail t,desired.oras rerluired ky the irupectcr of Mires. Estimated Value-of Electrical Work: (When required by municipal policy.) Work to Start: 2/Q�pZ laspections ec to tie req Aed in acurrdance with ME-C Rule 10,and upon completion, LNSURANCE COVERAGE Unless-waived b�'the owner,no permit.for the;performance of electrical Rork may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial'equivalent. TIM undersigned certifies that such covcmge is in force,and has exhibited proof of same to the permit i"siting off;ce- aiF,ck ONL: INSURANCE [R BOND ❑ OTHER ❑ (Specify:) I certify,under tlte.pains aiul pettalties of perjury,thal the information on Phis application is true and complete. FIRM NANM.: IC;NCD:: Al n7_17 Licensee: Larry A. Storace ,Sienature ?f� I:IC:NU:JE235-U— (Ifapplicahle,enter "ea-enipt"in `the license number line.) Bus,'Tel.No.: 781-322-9344 Address 50 Branch Street Maiden, MA 02148 Alt.Tet.No:: 781-322-9346 *Security System Contractor I.license required for this work; if applicable,eater the license n4:,mber here: ONV'FR'S INSURAINCE WAIVER: I am avvrare.diac the Licensee.does not have he liabilitvinsurance covera`t<-norinal?y required by law- By my signature be w I hereby waive ti s requirement I a n the(check one)❑o«mcr El c,';aau is a:trzxt. Ow ne'r;Agenf PL` ,Y_T'P'EF: Signature Telephone:No.__._ __._... - 55.