HomeMy WebLinkAboutMiscellaneous - 1401 GREAT POND ROAD 4/30/2018 (3) I� �l
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Permit ListinLy Report
Date Range:Issued between 01/01/2000 And 10/13/2015 by Permit Type Printed On:Tue Oct 13,2015
SQL Statement:Street No.like"1401"AND(Street like"GREAT POND ROAD"OR Work Location like"*GREAT POND ROAD*")and([Type of Permit]="Building")
Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details
Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check#
Building 1401 GREAT POND ROAD VANDERWALLE,ROSE LT&JOHN P& WINDOWS $2,463.00
RICHARD S CESERE,TRS
090.C/0023/ BP-2006-023 Expired Jul-11-2005 VANDERWALLE,ROSE LT&JOHN P& 5 REPLACEMENT WINDOWS
RICHARD S CESERE,TRS
$30.00 ON
RECEIPT
1401 GREAT POND ROAD KINSKY TR,KATHLEEN M KINSKY Roofing or Siding $16,400.00
FAMILY TRUST
BP-2007-445 Expired Dec-04-2006 KINSKY TR,KATHLEEN M KINSKY ROOF
FAMILY TRUST
$197.00 ON
RECEIPT
1401 GREAT POND ROAD RONSIVALLI,SARAH Residential Alteration& $51,000.00
Repairs
BP-2008-244 Expired Sep-28-2007 RONSIVALLI,SARAH REPAIR DECKS AND RAILS TO A CONDO COMPLEX
$604.00 ON
RECEIPT
1401 GREAT POND ROAD CONTE,MATTHEW Residential Alteration& $15,000.00
Repairs
BP-2009-621 Expired May-21-2009 CONTE,MATTHEW KITCHEN REMODEL
$180.00 ON
RECEIPT
1401 GREAT POND ROAD MANGAN,JUDITH Residential Alteration& $99285.00
Repairs
BP-2009-674 Expired Jun-08-2009 MANGAN,JUDITH RESIDENTIAL ALTERATION
$222.00 ON
RECEIPT
GeoTMS®2015 Des Lauriers Municipal Solutions,Inc. Page I of 2
Permit Listznz Report
by Permit Type
Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details
Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check#
Building 1401 GREAT POND ROAD VANDERWALLE,ROSE LT&JOHN P& Roofing or Siding $9,650.00
RICHARD S CESERE,TRS
090.C/0023/ BP-2010-077 Expired Jul-28-2009 VANDERWALLE,ROSE LT&JOHN P& STRIP AND REROOF MAIN BUILDING
RICHARD S CESERE,TRS
$116.00 ON
RECEIPT
1401 GREAT POND ROAD COLONAIDE ASSOCIATION DECK $23,000.00
BP-2010-126 Expired Aug-12-2009 COLONAIDE ASSOCIATION DEMOLITIION OF EXISTING DECKS.BOARDING UP
EXTERIOR DOORS.REBUILD DECKS
t
$276.00 on receipt
1401 GREAT POND ROAD COLONAIDE ASSOCIATION Residential Alteration $4,756.00
BP-2011-004 Expired Jul-01-2010 Jeannette Belben DEMOLITIION OF EXISTING DECKS.BOARDING UP
EXTERIOR DOORS
Replace 4 windows.Permit 004
$57.00 10174
1401 GREAT POND ROAD COLONAIDE ASSOCIATION Residential Alteration $3,650.00
BP-2011-784 Expired May-24-2011 COLONAIDE ASSOCIATION CEILING REPAIR,PERMIT 784
$44.00 0254
Permit Type(BUILDING)TOTALS: ESTIMATED COST: $135,204.00 NUMBER OF PERMITS: 9
FEES INVOICED: $1,726.00 FEES PAID: $1,726.00
BALANCE: S.00
GRAND TOTALS: ESTIMATED COST: $135,204.00 NUMBER OF PERMITS: 9
FEES INVOICED: $1,726.00 FEES PAID: $1,726.00
BALANCE: $.00
GeoTMSO 2015 Des Lauriers Municipal Solutions,Inc. Page 2 of 2
Project#9-107A
McBrie-, LLc
160 Sylvan Street y, y ` �,� .�' Telephone: 978-646-0097
Danvers, MA 01923 Structural Design & Sales Fax: 978-646-0087
www.mcbrie.com
AFFIDAVIT
STRUCTURAL DESIGN AND INSPECTIONS
TO: Mr. Gerald Brown
Inspector of Buildings
1600 Osgood Street NO I 6- T 6Arid FL--&---rk --
North Andover,MA 01845 -
L �
a
RE: Colonnade Condominiums–Exterior Deck Replacement
1401 Colonnade Condominiums
North Andover, MA
McBrie, LLC performed numerous structural framing observations at the above referenced project for the work
indicated on drawings S1 & S2 dated 08/11/09 issued by my office. The inspections were performed to review
the completed structural work. Based upon our observations, it is my opinion that the framing follows the intent
of the framing plans prepared by our office and any modifications which were made during construction meet
the structural requirements of the 7t' edition of the Massachusetts State Building Code.
aea
o. 41143
Structural Engineer MA Reg.No.
g £RhANI +
STRUCTUW 160 Sylvan Street, Danvers, MA 01923
No.41143 Address
y, iST
NAL (978) 646-0097
Telephone
Michael Perham
McBrie, LLC 12/07/09
Structural Engineers Date
On the —I-V ' day of �')2 rY4�c✓ , 20_CR before me,the undersigned notary public personally
appeared M�Ckq f_ ► P2/1n1�nit ,proved to me through satisfactory evidence of certification,which
was MA C1►/lU C'� �.<<e.-���,to be the person whose name is signed on the preceding documents,who
acknowledged to me that he signed it voluntarily for its stated purpose, and who swore or affirmed to me that
the c ntents of the document are truthful and accurate to the best of his knowledge and belief.
fNl LA I,. QA Afft-al G 2&=j rn!:S Q 1 to I'Z
Notar3VPublic PrintbU Name My Commission Expires
%
OF
® 9!
9-107A-Final Affidavit.doc Page 1 of 1 i���i�,�/'r'I I P
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec 3B
To: Building Commissioner or
Inspector of Buildings
City Hall
North Andover, MA 01845
To: Board of Health or
Board of Selectman
City Hall
North Andover, MA 01845
EOF
V
RE: Insured: Colonnade Condo Assoc. 2006
Property Address: 1401 Great Pond Rd ANDOVERTMENT
No. Andover, MA
Cause of Loss/Date: loss due to Water Damage Loss of 2/19/2006
File or Claim No: BOSO43986
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 LAWS, CHAPTER 143,
SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or file
number.
Mark Randall
Adjuster
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.
ignature Date
NEW ENGLAND CLAIMS SERVICE, INC.
100 CONIFER HILL DRIVE, SUITE 308
DANVERS,MA 01923
No Date
�` HORTM
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
••'•n T•D•�'�1_
SSACHUS�
This certifies that •` `
has permission to perform ..........
'
....s.'.................. .........................................
c wiring in the building of..........fit..........'
r..................................
at / ...........:. .'... ......'�............. .North Andover,Mass.
...................................
J
FeeA,4 0 r �
.............. Lic.No.............. .............................................f..................
/ ELECTRICAL INSPECTOR
Check #
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
` Jim WIYlivi"I vYI"GelL117 Vl'1VZe%j4"L., 1VaZI lJ vurce use omy
DEPARTIbl W0FPUBMk'CS4FE1'Y Permit No. ,3/0 g g`
BOARD 0FMEPREVEVH0NRWUL4TT0AN527CMR12:(JID Occupancy&Fees Checked -
VAPPUCATIONFOR PERAff TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 /
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat //
Town of North Andover To the spbctor of Wires:
The undersigned applies for a permit to perform the electrical work described below. �'�
Location(Street&Number) f y�l G1&,4-r- �.r> >�o 4,b ( L�/�v�4-0 e
Owner or Tenant
Owner's Address
Is this permit in conjunction building permit: Yes No (Check Appropriate Box)
Purpose of Building pith a .e•kl STING , g , w ,v . Utility Authorization No.
Existing Service Amps Volts Overhead a Underground No.of Meters
New Service Amps / Volts Overhead Underground No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work _C;-,.4't 1 r>►,>G ��
No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total
KVA
No.of Lighting Fixtures Swimming Pool Above Below Generators KVA
ground ground
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 Disposals No.of Heat Total Total No.of Detection and
Pum s Tons KW Initiating Devices
No.of Dishwashers Space Area Heating KW No.of Sounding Devices
No.of Self Contained
Detection/Sounding Devices
No.of Dryers Heating Devices KW Local Municipal Otter
Connections
No.of Water Heaters KW No.of No.of
Signs Bailasis
No.Nydro Massage Tubs No.of Motors Total HP
OTl nER
IrstaxtoeCo�erage Plasualtbthetegmartats�GataalLaws
Iha%eammitLi bi*hm==Pd yarkxd CattpideOpwfi nsCaaagecrilssi iafaltwalat YES FT NO
Iha%esubmAbdvatidptoofafsmm1otheOfi=YFS IBJ � If}wtmecfwdWYESpimseittdiatetheNxofwmaWbydxd gthl
Wpu
alebm-
INSURATBOND� OTHER ftaseSpo*)
EVirAmDdc
n
Fstirr>akd VahtedE 6Mical Walt$
Welkiostart i h>spodmDakRagttested Rough Fatal /r
SignedundaM
FIRMWAME Mkoilto ICC to/(' S P e s Lioa>seNa
Lioa�sae �s SF ' ���f SigttaUae �� � Z/ Liar>seNo - /'/47- /�
BtsiXssTeLNV
A � �✓_ r„�.�,�D r 1?cam •. AktTeLNoa
OWNERS MURANCEWAIVER;IamawatethattheL sedms not $teit>Suatoeeomage" ecgrivalatasmgtmedby Gaxr!Laws
a4a�atmyae«,a>�pal,�a�a,v�aas te�ar�
(Please check one) Owner 71 Agent
Telephone No. PERMIT FEE$ 6
No.: n 3 Date
NORrh 1
TOWN OF NORTH ANDOVER
to BUILDING DEPARTMENT
�9SSvt Building/Frame Permit Fee
cHus $
Foundation Permit Fee $
RECEIVED PAYTPermit Fee $
FEB 2 0 1992
s'o. Andover Colleen /� /Building Inspector
PER,mrr N,O. 0 3 Z APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ,✓ PAGE 1
MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK '.PAGE
y+ ZONE SUB DIV. LOT N I
LOCATION �7w PURPOSE OF BUILDING So
OWNER'S NAME /(/ NO. OF STORIES SIZE
OWNER'S ADDRESS BASEMENT OR SLAB
ARCHITECT'S NAME �fan� /I h/ SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME SPAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST Z 0.
PAGE 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER
FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL,OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
BOARD OF HEALTH
SIGNATURE OF OWNER UT 1 D AGENT
� OWNER TEL.#
F E E d-O CONTR.TEL.#
CONTR.LIC.#1.d, PLANNING BOARD
PERMIT GRANTED
19
BOARD OF SELECTMEN
BUILDING ECTOR
i
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY sr ES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFIFI CES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE d 1 2 13
CONCRETE EL K. PINE
BRICK OR STONE
PIERS PLPLTER
ASTER
_ DRY WALL _
UNFIN.
3 BASEMENT
I
AREA FULL FIN. B M T' AREA _
y, 1/s 3/4 FIN. ATTIC AREA _
NO B M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS ( 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH
ASPHALT SIDING HARDV✓'D _
ASBESTOS SIDING __ COMMCN _
VERT. SIDING ASPH. TILE —{I_
STUCCO ON MASONRY �—
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STIRS. & FLOOR—
BRICK ON FRAME
CONC. OR CINDER BILK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR I POOR _
ADEQUATE NONE
$ ROOF 10 PLUMBING
GABLE I HIP BATH (3 FIX.) _
GAMBREL MANSARD TOILET RM. (2 FIX.)
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK _
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER _
ROLL ROOFING -M DERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING I) 11 HEATING
WOOD JOIST PIPELESS FURNACE
_ FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
B'M'T 2nd _ ELECTRIC
1st 13rd I NO HEATING
0 4 W a wall IM r
INNAL FLANKNO..
NORTH ————— FWAL
Town of M 6 o Andover
0
No. 0 32a
V �17
X
-u d
V E� r er, Mani PA 2PC)WICK
00
PERMIT T 10 f
L 0 BOARD OF HEALTH
1 j 0
10 x
THIS CERTIFIESTHAf.� ,. . . ......Ic ............................ . .. ...
* BUILDING INSPECTOR
s on 04P6. ................ ........... Rough
has permissionib"ect ..... 110!Pl 1 . ..._
OW: Chimney
0 64-Or %V.... Final
to be upi ... ... ..........
I p lex P er
provided that the person accepting this permit shall in every respect conform to the terms of the application on rile in
PLUMBING INSPECTOR
this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough
Buildings in the Town of North Andover. Final
VIOLATION of the Zoning or Building Regulations Voids t 's Perm t.
PERMIT EXPIRES N 6 ONTHS ELECTRICAL INSPECTOR
Rough
UNLESS CONS RUC RT Service
Final
. ............... ...... ........
*iUILDI* 1Y1*N**S*P*E**C*T"0* GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Final
Display in a Conspicuous Place on the Premises
Do Not Remove Burner FIRE DEPT.
No Lathing to Be Done Until Inspected and Approved by Smoke Dot.
Building Inspector
Date. 0
".��T:1ti TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
1SSACNUSE�
This certifies that . . ( -.�.,.��< v c �� ;. . . . . . . . . .
has permission to perform . . . . .J)`! . . . . . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . .
at . . ,/L/Q/. . � A?� .�.���.`.North Andover, Mass.
Fee..N. . . . .Lic. No..Y'), '!� .. . . . . . . . /I� . �-c.�''�-- - - - - - - - .
J PLUMBING INSPECTOR
Check # 9 C."( I
7447
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO.DO. PLUMBING
-- - (Print or Type)
7v7�-0 r Pefmit
- Mass:,.- Date- 4—
-
Bul[ding Location f 4b1 Grt T RU . Owner4:Name Covet:
Type of Occupancy Y4,
New O Renovation 0 Replacement. Plans Submitted: Yes D No ;
FIXTURE
z
;1P16
as
al
Y N < C. 4.
0 i.: ur 1- :� .rp f. O` .Q Y .t U. d Fes'
,,j cc �.. eJ _ d c;
F- O > 1•' O N 2 O' O '
a Y .1 m'. W Q .G. '= Fes• .r u.. C t3 G C m.. 40
i SU13 SMT.
r BASEMENT
IST FLOOR
2No FLOOR
SRO FLOOR..
4TH FLOOR
STH FLOOR _
p
6TH FLOOR.
7TH FLOOR
STH FLOOR
Check one:. Certificate..
Installing Company Name �{
Address_ �,o,g,, 7Z y" C°rporation
JO a t,A;&,e. ,t _ AAA, nG L O.Partner-ship
Business Telephone �f g ► �E?D .( 4_ O FirmlCo. _
Name of licensed Plumber
INSURANCE COVERAGE:
l have a current liability insurance policy or Its substantial equivalent which meets the{equirements of MGL M. 142:
Yes. No O
if you have checked Yes. please indicate the type coverage by checking the.appropriate box.
A i'rabaity insurance policy Other type of indemnity:.:O Bond E3
OWNER'S INSURANCE WAIVER:1 am*aware Ahatlhd licenseedoes,not have.the insurance coverage required by
Chapter 142 of the Mass. General haws, and that•my signature:on this permit'appiftt.lon waives this requirement..
Check one:
Owner D Agent-Q.
Signatureal Owner or..Owner's Agent..
•
I.hereby certify that all of:the:details.and.information I#lave submitted4or entered)-in above;application are true and accurate to the ties!of my
ing:work and.'.installationsp� nder the permitlssued for this applicauart will be in
rformed ucompli
knowledge and that all pfumtiants with.all
pertinent provisions of the Massachusetts State Plumbing:Code sand.chapter.142 of the Genera(laws: ,
si
gnature of ucensed Plumber
Title
Type of License:Mastery .loumeyman p �1..
City/Town —OR—M.-
Master
-
License Number
SE ONL
APPF�ONED(0 IC .
Date...-3/-3//L,
� ,,, ....
NOR7M
°ft"`°;•.a TOWN OF NORTH ANDOVER
OL
0 p PERMIT FOR WIRING
19
SAC US
This certifies that I S AaAl f /1-C u,(r•... ......................... .......... ..
. ... .. .... . ..
has permission to perform /��i1�5 �.
wiring in the building of...... r
.... .... !... ,North AndoverMassat...... �
Fee rIl y Lic.No�, ....... . tr ......
//��... ..........
ELECTRICAL INSPECTOR
Check # -
4421
Nn= Commonwealth of Massachusetts
Oricol U �O��
IV
lyDepartment of Fire Services Pcrmit No.
OF FIRE PREVENTION REGULATIONS pcya =cc Checked
I/99 —O , �t
_
APPLICATION FOR PERMIT TO PERFORMELECTRICAL WOR KAll wuk to N--perionned in accordaucc with the MassachusettsEcalCd( N4t
(PLEASE I'RlAtT iN INK OR TYYPjE ALLnINFORM,4TION) Date:
City ur Town of /yD'
this application&the undersigned �rves notice o is or her intention to pe for/m the ele trtcr
Loocation (Street al work described below.
Number) o
Owner or Tenant �.
Owner's Address Telephone No. �
Is this permit in conjunction with a building perrnit? yes —
Purpose of Building N0 (Check Appropriate Boa)
Existing Set-vice Amps
IUtilityuthorization No.
Am _Verhead ❑ Undgrd ❑
New Service oults OvNo. of Meters
s / Volts Overread L ,
Ntlritbe►•of Feeders and Anipacity J Cadged ❑ No. of Meters
Location and Nature of Proposed Electrical Work:
Com letion o 'the ollowin table ma be waived by the ltu ctor o W
N°. of Recessed Fixtures No.of Ceil.-Susp.(Paddle) Fans
o. o Dial ires.
No. of Lighting OutletsNTransformers KVA
o. of Hot Tubs Generators KVA
No. or Lighting Fixtures A ove ri- o. o inergency Ig t rag
Swimming Pool orad. ❑
rtid. ❑ Batter Units
No. of Receptacle Outlets
No. of Oil Burners FIRE ALARMS No. of Zones
No. of Stvitclics No. of Gas Burners
o. o ctcction and
No. of Ranges Initiatirt Devices
No. of Air Cond. otal
Totes No. of Alerting Devices
No. of Waste Disposers cat ulnpum er ons
Totals: _"- o. o Sc f- ontatncd
No. of Dishwashers Detection/Alertin Devices
Space/Area Heating KW Local ❑ urtrctpa
No.of Dryers lection ElOtherO Heating Appliances KW ecurity ' stems.
0. 0
KW o. o 0 of or E uivalciit
Heaters Data Wiring:
SI us Ballasts No. of Devices or E uivaletit
No. Hydromassage Bathtubs No. of Motors Totrl HY
elccominunrcations rang:
OTHER: Nv.of Devices or E. uivalent I
INSURANCE COV Attach additional detoil ifdesired• or as required by the Inspector of Wires.
ERAGE: Unless waived by the owner, no permit for the per f-ormance 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 covsf}agc is in force, and has exhibited roof of sante t
CHECK ONE: INSURANCE�I p o the permit issuing office.
//E BOND ❑ OTHER ❑ (Specify:)
Estimated Value of Electrical Work: (tixpirntion Datc)
(When required by municipal policy,)Work to Start: Inspections to be requested in accordance; with EIEC Rule IU, and upon completion.
!certify, under rlte lnsgtrd penalties of perjury, that the information u« this application r� trete and complete.
FIRM NAME:
LIC. NO.: -s'
Licensee: �/� ��Sati Signa ur
(If applicable, enter exempt rn the!cense umber line.) LIC. NO.: �/j�j 7o7Y
Address: uY. TO. No.:
Oquirc by law.
ByANCC Wq[VFyZ•• ( am aware thatt(t.c Lice see does nor ave rite liability mswance coverage normally
Alt. TcL No.:
requ,rcd by law. By my si nature below. I hereby waive this requirement. i am the(check Dire) El owner Owner/Agent ❑owner's
Si�naturc
Telep'nonc tio. PCRIWT FEE: S