HomeMy WebLinkAboutMiscellaneous - 130 PLEASANT STREET 4/30/2018 130 PLEASANT STREET
+ 210/070.0-0006-0000.0
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9980
Date..... .........................
f HORTI�1
TOWN. OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACMUS�
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This certifies that .................................. . .........................
...................f..........
has permission to perform .......... .
'. A�tifTz winng m the buildm of......... ....................�..:..........I......... . .�. .... S
at...........3..........................................................C- 4�.�. N h Andover, ass.
Fee... ?............... Lic.No. .... 3 ........ .............. .. ..
_ ELECrRlcni.INsrEL R
Check # Z
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2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the
Permit
application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
n the prescribed form.After a permit application has been a:;cepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation's`MNd on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be.deemed-by the.Inspector_of_Wires abandoned.and.invalid.if_he—__. ._
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entitystated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending'tbrough August 15,2012.
ule 8—Permit/Date Closed: ***Note:Reapply for new permit
❑Permit Extension Act—Permit ate Closed:
"Commonwealth of Massachusetts Official Use Only
Department of Fire Services Occupancy and Fee Checked
Permit No.
BOARD OF FIRE PREVENTION REGULATIONS
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINTININKORTYPEALLINFORMATION) Date: .3
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)_ %3U �,(� f Q n
Owner or Tenant �ag i ��/ y S
Telephone No.
Owner's Address 5,A�.
Is this permit in conjunction with a building permit? Yes ❑ NoCheck Appropriate ppropriate Sox)
Purpose of Building Utility Authorization No.
Existing Service %44- Amps LY Volts Overhead D-_Und rd
g ❑ No.of Meters 1_
New Service Amps / Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table ma be 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 mergency11ighti
rnd. grnd. ❑ Batter Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
ev
No.of Ranges No.of Air Cond. Initiatin. Dices 3
Total
Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump Number._.Tons........ KW No.of Self-Contained
Totals: Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of WaterNo.of No.of Devices or Equivalent
• Heaters KW No.of Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motork Total HP Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Attach additional detail ifdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
(When required by municipal policy.)
Work to Start: 3 %6Yr G/ 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 m 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 true and complete.
FIRM NAME: /2v v 41
LIC.NO.:
Licensee: Z
.. , Signature ,�, LIC.NO.:��y y3
(If applicable, en t r "exempt"in the license numberline.)
Address: _ ¢d/ ,ri, ti s�' ,sr� / � Bus.Tel.No.:,1 4,L7-2lc y
*Per M.G.L c. 147,s.57-61,security work requires Department ofPublic Safety"S"Cense: Alt. c.No.l. :
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
ELECTRICAL PERMIT NO. TION
ELECTRICAL INSPECTOR-DOUG SCMALL PORT:
I-ROUGH INSPECTION:
Passed Failed—[ ] Re-inspection requirecl($50.00)
Inspectors'comments:
(Inspectors' ignature- o initi s) -
Date
.2.FINAL INSPECTION:
Passed—[ ] Failed—[ .] Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials)
. Date
3.UNDER..GROIM INSPECTION:
Passed—
[ ] Failed—[ j Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials)
Date .
F
SPECTION—SERVICE:E CALLED NATIONAL GRID: NAIVlE:
d—[ ] Failed—[ j Re-inspection required($50.00)ctors'comments:
(Inspectors'Signature--no initials), Date
S.INSPECTION-OTHER:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)
Inspectors'comments:
(1'nspectors'Signature-no initials) Date
D OOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A REINSPECTION OF$50.00 IS TO BE CHARGED.
1. ,
i.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
s 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/Zip: Phone #:
FED] loamlZole
employer?Check the appropriate box: Type of project(required):
employer with 4. ❑ I am a general contractor and Iees(full and/or part-time).* have hired the sub-contractors6 ❑New construction
proprietor or partner- listed on the attached shget. # 7• ❑Remodeling
shipsub-
contractors and have no employees These sub contractors have 8. E]Demolition
c� working for me in any capacity. workers' comp.insurance. 9. E]Building addition
[No workers' comp.insurance 5. EJWe are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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'
comp.insurance required.] 13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating they are 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.
I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
JQb 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 ofperjury that the information provided above is true and correct.
Signature: Date
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Per #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
L.6Other
ontact 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 shallnot 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 W
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
P P p 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
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
Location
No, 3 7 Date k
l,re4wz
A
0'�MOR, TOWN OF NORTH ANDOV6
3? •�•D I•,hoc
F a Certificate of Occupancy $ - M
Building/Frame Permit Fee $ f
sAC MUSEt Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $ �
Water Connection Fee $
TOTAL �&— j�� d
- uilding Inspector
12724 Div. Public Works
Location l 1 L� l ' r r, it
No, r.7 Date
f
0.1
A
R
NOWTN TOWN OF NORTH ANDOVERpp
p Certificate of Occupancy $
Building/Frame Permit Fee $ - �}
s i
;7 b'••°•'4�'
JNUFoundation Permit Fee $
SAC SE
Other Permit Fee $ ri
Sewer Connection Fee $
Water Connection Fee $
TOTAL $, JZ//
IBuilding Inspector
r t r t
- Div. Public Works
PERMIT NO. AI'1'LICATION FOR PERMIT TO BUILD**v ****NORT11 ANDOVER, MA
AL
I 11'NO. 'I
OGNO, 2. RECORD OFpN'NEI(SI111 DATE [TOOK PACE
7t)hE SUB DIY. i.Of NO. l J
1.0( A I ION 30 ee I'IIRI'116E 171 1)tlll l)IN(i �e ✓I�C .Sr O Q C� ' /''� 5 /�•�
OWNER'S NMIE cs QQ ? Q NO.OF STORIES SI :
OWN(iR'S ADDRESS 3 D I01AjeQ� � , ' BASEMENT(Ni SLAB rJe� see
AR('I II I ECI'S NAME J SIZE OF FLOOR 1 INIBURS I 2 3-
[it III
1IIIII DER'S NMIE ej ,, S,y, 1 SIAN
DISI ANCE TO NEAREST BUILDING DIAIFNSI(NJS OF SILLS
DIS I'ANCE I ROM STREET DIMENSIONS OF POS IS
DIS I ANCE FRMI LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS
AREA OF LOT FRONTAGE I IEICI IF OF FWNDATI(NJ Ti IICKNESS
IS B(11LDIN(i NEW 5171 of I(XTI INC X
IS BUILDIN(i ATN)I TION MA fERIAL OF CI ItLINEY
IS BUILDING ALTERATION c IS BUILDING ON SOLIDOR FII LED LAND
WTI.I.BUILDING CONFORM TOREQ)(IIREMENISOFCOOE ,,15 IS WILDING C(NJNECIEDIOTOWN WAIER
1)().4RDOFAPPEALS ACTION,IF ANY IS BUI LIN NG CONNECI ED TO TOWN SEWER
IS BUILDING CONN)CI ED TO NA FURAL GAS LINE
INSTU('TIONS 3. PROPER'11'INFORhIAI ION - LANDC'OST
ESI.61.1)G.COST d�
DACE I FILL OtfFSECTIONS 1-3 ES 1'.BLDU.COST PER SO. FT.
ESI. BI.W.COS I PER R(X)M
ELECTRIC METERS MUST BE ON O(JTSIDE OF 0011.)ING SEI 1IC PERMI f NO.
AFTACIIEDGARAGESMUST C(NJFORM'I'OSTATEFIRE REGOLATiNJS �. API'It01'f:DBY:
PLANS MUST BE FILED AND APPROVED BY B1111.DING INSPECTOR DII.DINC INSI'F.(:FOIL
.DAIEFit ED g O)1I OWNERS11:11
C(NJIRAE111 &(b -7CM
` COMR.1.1(11 �Q�'7Z�
SI(iN.A fI RF:OF (RAIffIX)RI'LI:DAGENT.
11.1.C'.s
11i11Al1T CRANfED s>'4-
19
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®weer Acs • Pe er Aje7
A] , AL ct ✓ 11414i
40 slc\1014
e
R� � 7
�~ TAO R T
F
Town of 9 over
No. 3 a 7
* 0 z . dover, Mass.,
19
0 LAKE �
COCHICHEWICK iY',�•
Oq4 TED
S E BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
�� BUILDING INSPECTOR
THIS CERTIFIES THAT .
............. ...... ............. #.Y.... •.................................................................,............ Foundation
has permission to erect...... buildings on........ ........P.�.A..�... .t....� ............... Rough
to be occupied as.......... .tn
gth"i ... ..... ............. Chimney
rovided that the erson acce this permit shall in every respect conform to tf"ie terms of the application on file in Final
P P Pg
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
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION TARTS Rough
. . . ... .. ........ ......
Service
UILDING INSPECTOR
Final
Occupancy Permit Required o Occupy Building GAS INSPECTOR
la in a Cons icuous Place on the Premises — DorNot Remove Rough
Display Y � PFinal
No Lathing or Dry Wall To Be Done
Until. Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
Burner
ec 1Street No.
19,7a� Smoke Det.
q 51
Date. .�.lr. /�3,G..... ..
e ! f
NORTH TOWN OF NORTH ANDOVER
,4,
0 PERMIT FOR GAS INSTALLATION
SSACMUSEt
This certifies that . . .P. j . . . . . . . . . . . . . . . . . .
has permission for gas installation . .!H. . . . . . . . . . . . . . . . . . . . . .
I
in the buildings of . .r.�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . ,�. <<. `! ���` . .� . . . . . . ., North Andover, Mass.
Fee./2.4 . . . Lic. No. 3.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
GAS INSPECTOR
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
` I
• MASSACHUSETTS UMFORM APPLICATOR FOR PERMIT TO DO GAS FITTING
Type or print) Date 1116, 19
NORTH ANDOVER, MASSACHUSETTS �r7
Building Locations 1y / Z S Permit# r7�
Amount S
Owner's Name A GZ V
New❑ Renovation ❑ Replacement 0 Plans Submitted11
❑ ,
m ^'
n rn n C zn
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c; Cn = z
w =c c w
n r WC: C -t
z -t m :r Z ` n M z w C m
w w _ z _ -c C C = C w —
SU B-BA SEM ENT
B A S E M E N T
IST. FLOG R
2;N D . FLOOR
3RD . FLOOR
1T 11 FLOOR
5TH . F1, 00 R
6T H . F L O O R
7TH . FLOOR
VT 11 . F LOO R
(Print or type) Check one: Certificate Installing Company
Name ( I ��. / G�il <---� ��` ❑ Corp.
Address 422 .�Q X Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber or Gas Fitter �)�i� l-� �-/ sP�2 4-ze
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0-- No❑
If you have checked ves.please indicate the type coverage by checking the appropriate box.
Liability insurancepolicy ❑' Other type of indemnity ❑ Bond F-1
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.
Check one:
Signature of Owner or Owner's Agent 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 installation performed under Permit Issued 1'or this application will be in
compliance with all pertinent provisions of the Mass achusetts,S dte OCode and Cha er 142o e Gen Laws.
By:
Signature of Licensed Plumber Or Gas Fitter Title ®' Plumber .0 3
City/Town ® Gas Fitter Icense i umoe.
Master
APPROVED(OFFICE USE ONLY) ❑ Joumevman
Date... .. .
MORIN
TOWN OF NORTH ANDOVER
F? Lp
PERMIT FOR WIRING
A US�
This certifies that ....... / - S � if ( — ( �I`r'
... . . ...... n
has permission to perform ....... ......... r...........
wiring in the building of
at.....,.�..............�J............s............... ...............,,,North Andoyerl/amass.
Fee.' )............ Lic. /% ..
ELECTRICALI SN PECTOR
Check #
465 >
-� Official us
Commonwealth of Massachusetts e olay
� .
J Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancyand Fee Checked (�
[Rev. 11/99] 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 W INK OR =ALL INFORM47I01v) Date: 7 —> y - - 3
City or Town of: /V A To the Inspector of fres:
By this application the undersigned gives notice of or her intention to perform the electrical work described below.
Location(Street&Number) ,::7;
Owner or Tenant SVA; -. ' Telephone No.
Owner's Address .--Z
Is this permit in conjunction with a building permit? Yes ❑ No E�—'(Check appropriate Bos)
Purpose of Building c- � -Y Utility Authorization No. 3?�'
Existing Service Amps / Volts erhead ❑ Undgrd❑ No.of Meters
New Service ori Amps /-2t/ 12 YO Volts Overhead❑'"` Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: L°�Y
Completion of dee following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
o. of Lighting Outlets No. of Hot Tubs Generators KV A
No.of Lighting Fixtures Swimming Pool above ❑ In- ❑ i 0. o Emergency Lighting
rnd. arnd. Battery Units
No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No. of Switches No. of Gas Burners No. of Detection and
Initiatin Devices
No.of.Ran es No.of Air Cond. Total
g Tons No.of Alerting Devices
No.of Waste Disposers eat Pump i umberons W 9No.of Self-Contained
Totals: - Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances , Security Systems:
No.of Devices or Equivalent
No.of Water
No.o.of
TO-.o. of
Heaters KW Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of ryires.
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. 7a.-
undersigned
'neundersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 3
(Expiration Date)
Estimated Value of Electrical Work (When required by municipal policy.)
Work to Start: 7 2 y •-c- _-3 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete-
FIRM
ompleteFIRM NAME: a0- � � LIC.NO.: .12
Licensee: �pr.,l s !' Signature w LIC 0.; / y'93-
(If applicable,a er "exempt"in the license number line.)
Bus7 ei.No.: P-9 o
Address . r / y
/� e
a/ci S �.- Alt.Tel.No.:
OWNER'S S INS URAi CE Y W
AIVER: I am aware that the icensee does not have the liability insurance coverage normally
required by law. B signature below,I hereby waive this requirement. I am
Y my 1'� Y Q the(check one) ❑ owner ❑ owneraeent.
Owner/Agent
Signature Tnlonhnnn pFRINTT FFF• ' .
Nr.