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HomeMy WebLinkAboutMiscellaneous - 130 WEYLAND CIRCLE 4/30/20180- 4 0 0 0 0 Date.. /� . �..?z....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... c -r -....... .............................................................. has permission to perform---..-� wiring in the building of ..........�....."............................................................ at n -s .. North Andov Mass. Fee-; ............. Lic. No&�� .......... 4 CTR�� ,'' ELEICALINSPE R Check # 9'i 34 Y Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked" tev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 MR 12.00 (PLEASE PRINTMAW INK OR TYPE ALL INFORMATION) Date: // / D� City or Town of: NORTH ANDOVER To the In sp ctor of Wires: By this application the undersigned gives n tice of his or her intenti n to pe�jorm the electrical work described below. Location (Street & Number) /.30 11f 10 _ [Y 12;,tn► Owner or Tenant Owner's Address °telephone No. Is this permit in conjunction with No❑ a, uilding mit. es' 1 (Check Appropriate Bog) Purpose of Building I / Utility Authorization No. Existing Service Amps / _Volts Overhead ❑ Und d gI' ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: A f, No. of Recessed Luminaires Completion of the followin table may be waived by the Inspector of Wires. No. of Ceil: Susp. (Paddle) Fans No. of Total No. of Luminaire Outlets No. of Hot Tubs Transformers KVA Generators KVA No. of Luminaires SwimmingPool Above In- d. El o. o mergency ig g El No. of Receptacle Outlets d. No. of Oil Burners Batte Units FIRE ALARMS No. of Zones No, of Switches No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond. Total Initiating Devices Tons No. of Alerting Devices No. of Waste Disposers Heat PSP Number Tons KW Totals:__................_.._....._.._........................._. No. of S4f-Co ntained No. of Dishwashers tion./Alerting Devices Space/Area Heating KW Local ❑ Municipal 2 J ❑ mer No. of Dryers No. water Heating Appliances KW Connection Security Systems: * No. of Devices of Heaters KW No. of No. of or Equivalent Data Wiring: Si s Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices ar F.tn1GV01A-+ .Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) 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 ' ance including "completed operation" coverage or its. substantial equivalent. The undersigned certifies that such cove is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Spec I cetWft, under the gn penalties o erjury, th' t the i mation on this application is true and complete FIRM NAME • L LIC. NO.M' 7 Licensee: ewn Signature (Ifapplicable, a ter exe pt "in helicense number r e LIC. NO.: Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security w k requires Departm t of Public Safety "S" License: Alt. TelLic. 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 Signature Telephone No. PERMIT FEE. $ l / / RA4 /4t A - Location ; No. ClDate l0 TOWN OF NORTH ANDOVER A Certificate of Occupancy $ Building/Frame Permit Fee $ yssACMUSE� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ - Water Connection Fee $ TOTAL $ Building Inspector 14/18/96��11 1,146.00 PAID !q Div. Public Works PEIiJtIT NI -f APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 1! PAGE 1 MAP iqO. I LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. 1 - LOCATION 1 ` 1..� `! / a 1 ' W 7 is `/�l�C N PURPOSE OF BUILDING OWNER'S NAME�— NO. OF STORIES �n SIZE s^- OWNER'S ADDRESS h � �u �h { ✓J/ '5 � �7 /! BASEMENT OR SLAB y s� ter ARCHITECT'S NAME �{�J �• D/ �ra� SIZE OF FLOOR TIMBERS 15T�aq//a 2ND �1 D 3R BUILDER'S NAMED_/xC�Od „/ y Priv 14 SPAN /`�Lk DISTANCE TO NEARE T BUILDING fr]Li (/�Llllil j -��T/` DIMENSIONS OF)SILLS -— "' POSTS 2 /1 DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES /��1 t REAR GIRDERS AREA OF LOT 2.9419 FRONTAGE � � �'� HEIGHT OF FOUNDATION THICKNESS /o � v IS BUILDING NEW 11--e 5 SIZE OF FOOTING a /r X O IS BUILDING ADDITION MATERIAL OF CHIMNEY 4 at SQ h IS BUILDING ALTERATION /j / IS BUILDING ON SOLID OR FILLED LAND _J GL WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS IS BUILDING CONNECTED TO TOWN WATER Y S i! BOARD OF APPEALS ACTION, IF ANY "A IS BUILDING CONNECTED TO TOWN SEWER e s IS BUILDING CONNECTED TO NATURAL GAS LINE P/e5- INSTRUCTIONS SEE BOTH SIDES /,q/ -0 PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILEDfUJ�hl- z 0 I/ r SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE `o, , PERMIT GRANTED 19--�L�^-- tl-- 3 PROPERTY INFORMATION LAND COST] EST. BLDG. COST EST. BLDG. COST PER SQ. FT.� V EST. BLDG. COST PER BLDG. COST PER ROOM , SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSP[CTOR OWNERTEL.# 0 _ ?L >y CONTR. TEL. # (o` 7 ?d CONTR. LIC. # 16 Q 10 H.I.C. # TAR & GRAVEL ROLL ROOFING STALL 5HOWtR MODERN FIXTURES BUILDING RECORD 1 OCCUPANCY 12 TILE FLOOR SINGLE FAMILY - STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. €AMILY�!� OFFICES ' LOT LINES AND EXACT` DIMENSIONS OF -BUILDINGS. WITH PORCHES. GA - APARTMENTS' ' 11 HEATING FURNACE RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. , CONSTRUCTION` FORCED HOT AIR FURN."� STEAM STEEL BMS. & COLS. WOOD RAFTERS 2 FOUNDATION HOT W'T'R OR VAPOR 8 INTERIOR FINISH" .t CONCRETEd _ 7 NO. OF ROOMS B'M'T2nd _ 1st 13rd I RADIANT 1 2 13 CONCRETE BL'K. PINE ELECTRIC NO HEATING BRICK OR STONE HARDW D PIERS PLASTER DRY WAIL UNFIN.'iae _ _ $ BASEMENT I ; AREA FULL - - FIN. B'M'TAREA _ 1/1 1/7 % FIN. ATTIC AREA ' m NO B M'TFIRE PLACESF- HEAD ROOM AAODERN' KITCHEN 4 WALLS 11 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING ` ' CONCRETE �_ WOOD SHINGLES. EARTH ASPHALT SIDING' HARDW D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY - STUCCO ON FRAME �- BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC."-OR CINDER' BILK. STONE ON MASONRY WIRING w STONE -ON fRAMf % _ SUPERIOR I� POOR _ ADEQUATE NONE j ROOF 10 PLUMBING GABLE I HIP GAMBREL MANSARD BATH (3 FIX.) TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ wnnn cuwaoc KITCHEN SINK TAR & GRAVEL ROLL ROOFING STALL 5HOWtR MODERN FIXTURES _ _ , TILE FLOOR TILE DADO 6 FRAMING J1 O WOOD JOIST'PIPELESS 11 HEATING FURNACE ' TIMBER BMS. 6 COLS. FORCED HOT AIR FURN."� STEAM STEEL BMS. & COLS. WOOD RAFTERS HOT W'T'R OR VAPOR _ AIR CONDITIONING1�, _ 7 NO. OF ROOMS B'M'T2nd _ 1st 13rd I RADIANT UNIT HEATERS GAS OIL ELECTRIC NO HEATING Q`r CN Ok rA rb. Rf x w A y O wuu w z Z A (� c -Uro 0 P V J\ICOI ro GG O H w z _w co � 0 w 0 5 cn ro . � O H w Aw GO b° �D �u _cz z w A w w v co Cf) O� nU) 0 _ o Z CD Q. O 0 IC "C y a.,0 CD , E— CD CD O R O = CL CMCX EA C © l4 .� z Q 0 CL V rA c too r 0 _CO V J\ICOI i c 0 :moo :oma C N :o= co E� U ot h--4 C� n {p R O O C . = O Cc CL o �,. ++ N E c 9 :o t5 cm m c E CL=L co L a N Q: O z N m J N Cf m N C u EN R i \I111�► co O O. U L: m N CO O Q = L m O C � R '> Z O O. 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This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: k I&LO o © N 0-(� a l `�"y CAL Phone LOCATION: Assessor's Map Number Parcel Subdivisions x'1A,0 eW Lots c ) Street co -C /V- St. Number /3 U ************************Official Use Only************************ RECOMMENDATIO S OF O AGENTS: -/� Date Approved ro pp Conservation Admini trator Date Rejected _11-iLL Comments Town Planner 'Comments I Food Inspector -Health Septic Inspector -Health Comments Date Approved 30 Date Rejected, Date Approved Date Rejected Date -Approved Date Rejected Public Works - sewer/water connections ��,- C�`C� ��19J6 - driveway permit -7c Fire Department ;i Received by Building Inspector Date No 661 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. QJ' ;30 19 Application by the undersigned is hereby made to connect with the town water main in w C �' Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. or sub2 division lot no. /G . Xwew/ Owner Contractor (71 %Z",� Address Address Applicant's Signature PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to Z L �Oc7/� Z& to make a connection with the water main at (14J subject to the rules and regulations of the Division of Public Works. Inspected by Date (/-, (�a L Street Street oard f Public Works —/—/" ',;S, (�� By , See back for rules and regulations RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Towr of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be V type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4�/Z foot rod and brass plug type cover. N° 1187 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass.L-3/) g `CJ Application by the undersigned is hereby made to connect with the town sewer main in c/l � Street, subject to the rules and regulations of the /Division of P/u'b�li� Work . The premises are known as No. C Lt Z Street or subdivision lot no. Owner Contractor PERMIT TO CONNECT The Division of Public Works hereby grants permission to to make a connection with the sewer main at (Q� subject to the rules and regulations of the Division of Public Inspected by Date Address Address Applicant's Signature RMAIN ///y]� i>,'."l / /r Street �. Division of Pub is Works By See back for rules and regulations RULES AND REGULATIONS FOR GOVERNING THE INSTALLATION OF SEWER SERVICES 1. No unauthorized person shall uncover, make any connections with or opening into, use, alter, or disturb any public sewer or appurtenance thereof without first obtaining a written permit from the Division of Public Works. 2. All costs and expense incident to the installation and connections of the building sewer shall be borne by the owner. The owner shall indemnify the (town) from any loss or damage that may directly or indirectly be occasioned by the installation of the building sewer. 3. A separate and independent building sewer shall be provided for every building; except where one building stands at the rear of another on an interior lot and no private sewer is available or can be constructed to the rear building through an adjoining alley, court, yard, or driveway, the building sewer from the front building may be extended to the rear building and the whole considered as one building sewer. 4. Old building sewers may be used in connection with new buildings only when they are found, on examination and test by the (Superintendent), to meet all requirements of this ordinance. 5. The size, slope, alignment, materials of construction of a building sewer, and the methods to be used in excavating, placing of the pipe, jointing, testing, and backfilling the trench, shall all conform to the following requirements. The sewer shall be 6"diameter SDR 35, PVC pipe. Minimum slope shall be 1/8" per foot. The minimum depth of sewer shall be four feet below finish grade. Sewer pipe shall be installed on a stable trench bottom of hard durable crushed stone to a minimum (6) inch depth below the pipe. After the pipe has been installed, crushed stone shall be brought up to the crown of the pipe. Care shall be taken to carefully grade and compact the stone, and prevent pipe displacement. The remainder of the trench shall then be backfilled in one foot lifts with mechanical tamping after each lift. 6. Whenever possible, the building sewer shall be brought to the building at an elevation below the basement floor. In all buildlnis in. which any building drain is too low to permit gravity flow to the public sewer, sanitary sewage carried by such shall, be- lifted by an approved means and discharged to the building sewer. 7. No person shall make connection of roof downspouts, exterior foundation drains, or other sources of surface runoff or ground water to a building drain which in turn is connected directly or indirectly to a public sanitary sewer. 8. The applicant for the building sewer permit shall notify the (Superintendent) when the building sewer is ready for inspection and connection to the public sewer. The connection shall be made under the supervision of the (Superintendent) or his representative. 9. All excavations for building sewer installation shall be adequately guarded with barricades and lights so as to protect the public from hazard. Streets, sidewalks, parkways, and other public property disturbed in the course of the work shall be restored in a manner satisfactory to the (town). DRIVEWAY ENTRY PERMIT Date: LOCATION /4, BUILDER TEL: OWNER C®r TEL: 4t i The North Andover Superintendent of Highway Utilities & Operations MUST be notified of the grade and set -back from street established in any driveway entry onto any street or way maintained by the Town. Call the Highway Superintendent's Office, before finish grading and surfacing for approval of such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. Remarks; Approval: r o o - 'e- ;oGa.00� Lq,v� i.2 C LE �GQT- IC�4/9it/ /N �A OF A448 JEFFREY qO� O.PgfYN FO.P o Sv— $ 6 .2 fs� S. E ///.4.�/•oGE' .vT E � t m o FhJ1N i � NO N y a�#36381P� i9 �S > 'o yz 9� O A rE f�flGt� E.l�G�•dEE,P�.f/G SE.PY/lES 6� f'q•P,t� -S"T,PEET A't/ODYE.P, �Y/,4SS,gls/l/SETTS o/8/O Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address /o'f'Property for Permit (below) Mapy 6rq and Parcel : Purpose of Application (check below) Phgna Hume r off Applicant: Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Kla. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my kno ge or not, is grounds fqs refu I by the Building Department to issue a Building Permit. 4A6 nature of Owner or Authorized Aaent who sinned the Attached Buildina Permit Dat This form must be attached to the Building Permit upon application for such permit. s•. hLAWA c w- 0 c ts : O � c � O N �p O � . . C3 c3 QLc O C C5. O CLU- N �O' o C " o i EN E 0 CDt f,Ka � "� •• N cc m ai Q �3 s V• Q! 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BAY STATEADJUSTMENT SERVICE 45 New Ocean Street, Swampscott, MA 01907 Telephone Numbers 24 Hour Emergency Number (781) 858 1075 (781) 599 9922 (800) 865-2206 FAX (781) 599 9099 Town Fire Department Inspector of Buildings Town of N. Andover Town Hall N. Andover, MA 01845-4935 Re: Vincent & Maria Arone Property Address: 130 Weyland Circle N. Andover, MA 01845-4935 Policy Number: HP2127776 File Number: 2084 Board of Health Town of N. Andover Town Hall N. Andover, MA 01845-4935 Company: Cambridge Mutual Fire insurance Company Date of Loss: During Winter Cause of Loss: Water Damage Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Law, 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 and include a reference to the captoned insured, location, policy number, date of loss, and file number. This is not a request for a report, this is to comply with Masschusetts notification laws as set forth above. Paul R. Nestor, Jr. Adjuster On this date, I caused copied of this notice to be sent to the persons named above, at the addresses indicated by first class mail. r12&d April 8, 2002 Signature ;; Date Me.+�of the/NatwnaZAs"aott'owof Ivuc7p-pe+ de In44u-a+tce/AdjWte4 s, BAY STATE ADJUSTMENT SERVICE 45 New Ocean Street, Swampscott, MA 01907 Telephone Numbers 24 Hour Emergency Number (781) 858 1075 (781) 599 9922 (800) 865-2206 FAX (781) 599 9099 Fire Department Inspdfor of Buildings Town of N. Andover own Hall N. Andover, MA 01845-4935 Vincent & Maria Arone Property Address: 130 Weyland Circle N. Andover, MA 01845-4935 Policy Number: HP2127776 File Number: 2084 Board of Health Town of N. Andover Town Hall N. Andover, MA 01845-4935 Company: Cambridge Mutual Fire Insurance Company Date of Loss: During Winter Cause of Loss: Water Damage Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Law, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captoned insured, location, policy number, date of loss, and file number. This is not a request for a report, this is to comply with Masschusetts notification laws as set forth above. Paul R. Nestor, Jr. Adjuster On this date, I caused copied of this notice to be sent to the persons named above, at the addresses indicated by first class mail. April 8, 2002 Signature J Date Me,vt� of the, of IvLde a devLtIn4twa vu AcyWtev-s, Date . U/ `. 1!' 566 .......... .... f NORTI{ 7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...................�!�lat...,.........�.... has permission to perform ............/..�,t �✓........ .... ...............=........... wiring in the building o Y ..... ..i ........................ at ......./3. Z ...... ..... a-,--,,NorthAndover, Mass. Fee. LIc. No....... Q,1q:.••••••................................................... ELECTRICAL INSPECTOR 1 01l9� li� e` 175.50 PAID WHITE: Applicant CANARY: Building Dept. PIN :Treasurer uhe Lfommonwettlth of fagsarhuseits Bepartmart of Public *ufetq BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only ! Permit No. Occupancy ,& Fee Checked 3190 geave blank) 7 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cade, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date // - / ` g/ 6 IN* or Town of NORTH ANDOVER To the Inspector of wires: The udersigned applies for a permit toperform the electrical work described below. Location (Street & Number) /_6 o ✓�/l Owner or Tenant 6 Y tA Q C !)-Q A I Owner's Address 7 _ !s -his permit in conjunction with a building permit: Yes No _ (Check Appropriate Boxj Purccse of Swirling I"_'3 -JG N 0\ Utility Authorization No. (l L� Existing Service Amps `dcits Overnead - Uncgrnd f-7 No. of Meters New Service ZUU Amps tom/ ZkU `nits Cvernead Undgrnd ! No. of Meters Number of Feeders and Ampacity Locat,en and Nature of Proposed Eiec:r:cal 'Nerx Hot i No. of Transformers :o.ai No. of Ugntinc Outlets No. cf Hot -.:cs K%!A No. of Lighting Fixtures Swimming Pool 4Ccve— 'n- g 9 gm..e. _ ;mc. .— Generators KVA i No. of Emergency Lgnt!ng No. of=;eceotacie Cutlets Na. of Cil °umers Battery Units No. cf Switch Outlets No. of Gas Burners � FIRE ALARMS No. of Zones No. of Cetec:ion arc Initiating Devices I J Tota, No. of Ranges !. No. cf Air Ccnd. ors I No. of Sounding Devices Heat Tc;ai -' No. of Disoosals No.cr Pumas Tons C:J No. of Sart Contained No. of Dishwasners Scace,Area Heating C.v ' Detection/Souncinc Devices — Municipal Other L acal Conneciron _ No. of Orvers Heating Devices K.'J No. of Nc. v I Low Voltage I No of Water 4eaters KW S;cns Ba: as:s Wiring No Hyaro Massage Tubs No. of Motors 7otai HP , OTHER: INSURANCE COVERAGE: Pursuant to the recwremen;s of 'v1assachL;ser*s gereral Laws — ! have a current Liamiity Insurance Policy inc:ucirc Comc:etec Ccerat:cns Coverage or its suost— antiai ecuivaient. YES NO 1 nave sucmitted valid proof of same to the Cffics. YES .4 NO = :f you nave cnecxed YES. please indicate ;he type of coverage cy Checking the aci croonate box. INSURANCE A BOND = OTHER = ;Please Scec:`:) 1 (Expiration Date) Estimated Value of Electrical Worx 5 0 R w t �� Co..l( Final '.vorx to Stan //,/- v/ �' inspec::cn Date Rac::es:e_• ougn Signed unser :he Penalties of perjury: F!R.M NAME G • L;C. NO. Licensee CIA / n, \ r`E' n.S�Signature� _!C`NO. Bus. lei. No. _ (� Address un4" � A I Alt. 741. No. C NER'S ;NSURANCE .'JAIVEa: I am aware that -re Licensee cces not have the insurance coverage or rts suostannat eaurvalent as re- cuirea cv Massachusetts General Laws. and :hat my signature on :his cermet application. waives :his reduirement. Owner Adent ;P!ease cnecx ores 7eieonone No. PERMIT FEE S (Signature of Owner or Agenu