HomeMy WebLinkAboutMiscellaneous - 151 CARLTON LANE 4/30/2018 r151 CARLTON LANE^.
2101106.0-0082-0000.0
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NORrh
°� "`° '•�� TOWN OF NORTH ANDOVER
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PERMIT FOR WIRING
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....This certifies that �.
has permission to perform ....
wiring in the building of............... .cam.4.. .....................................................................
a�...............I ...............:... ? .'. .!'�.....t-'`?:........ orth Andover,Mass.
Fee��............Lic.No .................. . .....:. .... . ......
ELE CAL WSPEMR
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11516
Commonwealth of Massachusetts OfficialUUsseeOnly
Permit No. //J /
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS
,[Rev.1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),5/27 MR .00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 7 v, /a
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) /-V/ C4v'/1001 Ei✓
Owner or Tenant kAAX-IwA./ C-o-d Telephone No. e7y
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate)3ox)
Purpose of Building o"se, Utility Authorization No.
- Existing Service ;!00 Amps /7 LID Volts Overhead❑ Undgrd No.of Meters
New Service 00 Amps IZO/Z`IU Volts Overhead❑ Undgrd No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: pp A to �trroy^ e lec-1 i C
Re e he
Completion of theollowing table may be waived by the Inspector of Wires.
No.of Total
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
AboveIn- o.o mergency ig ting
No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
Tot
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW.......... No.of Self-Contained
P Totals: Detection/Alerting Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection ElOther
Heating Appliances KW Security Systems:Y
No.of Dryers No.of Devices or Equivalent
No.of WaterKW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
Telecommunications Wiring:
No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of El ctric 1 Work: (When required by municipal policy.)
Work to Start: l�� t'3 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 cover e is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE , BOND ❑ OTHER ❑ (Specify:)
I certify,tinder the pains and penal fes ofperjury, 11 t the information on this application is true and complete.
FIRM NAME: , Nr G r o LIC.NO.: � ,0550
Licensee: �� SignatureJ�kz LTC.N9.: �.SOS.SQ
—� „ .
(If applicable,enter"exempt zn the license number line.) Bus.Tel.No : V7f f/a3"SGi/
Address: ��� 3M-1,4Ate/ �� r k",// ",4 a/W Alt.Tel.No..
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.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 PERMITTEE:$
o, a.. Tplanhnnn Nn_
❑ 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
on the prescribed form,After a permit application has been accepted 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 stated 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 entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 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 through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass F?] Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
F
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass M Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass M XFailed 0 Re-Inspection Required($.)❑
Inspectors Com ents:
r" 4(—/L - /_3 6107-
V J
oe/ [(
Inspectors Signature: _ a I e:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
y ,
The Commonwealth of Massachusetts
- Department ofIndustria.I Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
to www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers lease Print bl
Applicant Information /�
Name(Business/Organization/Individual): FAJA4nn (9
Address: �/6 �`�M�✓
City/State/Zip: L G �r l /1 ,_ Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.721oyees
employer with 4. ❑ I am a general contractor and I 6. [�New construction
full and/or art-time .* have hired the sub-contractors( p ) listed on the attached sheet. ❑Remodeling
2. sole proprietor or partner-
ship and'have no employees These sub-contractors have 8. ❑Demolit' n
working for me in any capacity. workers'comp.insurance. g B ' g addition
' [No workers' comp.insurance 5. ❑ We are a corporation and its 10. lectrical repairs or additions
required.] officers have exercised their
ri ht of exem tion er MGL 11.❑Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work g p p
myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensationpolicy information.
Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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 workers'compensation insurance for my employees. Below is the pollcy and job site
information.
Insurance Company Name:.
policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: lCitylstatelzim
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
Investigations of the DIA.for insurance coverage verification.
Ido hereby cern a pains a s o perjury at the information provided above is true nd correct.
Si ature:
c Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
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#:
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 shall not 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
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 cant'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 youare 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. f
Please be sure to fill in the permittlicense 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 ou 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 bum 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,0.2111
TO.#617-727-4900 ext;406 or 1-8777MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass,govldia
- s
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ELECTRICIANS
AS A,REGJHOURNE LABOVE ICENSE TO:
RAYMOND 6 RICHARD JR
11 . TAYLOR STREET
I
SALEM NH 03079-254
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Sn_ n E Q713111319401
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
5z^,.`��},� .c A # WOW"!
,
BUILDING PERMIT NUMBER: DATE ISSUED: X
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Pr y Address: 1.2 Assessors Map and Parcel Number:
��f5i
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Rcquired Provide Required Provided Required Provided
1.7 Water Supply M.G.L.C.40.11 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0
SECTION 2-PROPERTY OWNERSHWIAUTIIORIZED AGENT Historic District: Yes No M
2.1 Owner of Record
Ga,:"� V Ce,Sy ------ l 5 t �yltan L.,L
Name(Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
M
Signature Tele one
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction-)6-41,
upervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home(Improvement Contractor ) Not Applicable ❑
Company Name ? M
a
PAY j y r Registration Number rM
J o �� �
Address
Expiration Date V
Si nature Telephone �i'
SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) '
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building it.
Signed affidavit Attached Yes.......0 No.......0
SECTION 5 Description of Proposed Work check au applicable)
New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
w Jaw YN Y6 v l
moo.
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be @FFICIAL'V-
-n Ql+t ,y
Completed by permit applicant ��
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)X(b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 'a-V Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize ���� to act on
My behalf,in all matters glativ to work authorize by this building permit application.
Signature of Owner V Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Sig2ature of Owner/A ent Date
NO,OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS 1 2ND 3RD
SPAN
DA ENSIONS OF SILLS
DIN ENSIONS OF POSTS
DlIvIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
MORTGAGE INSPECTION PLAN
J �
to'! 3(0
4T4
y;00 _.
Gam.
THIS PLAN IS BASED ON ATAPE SURVEY(NOT AN INSTRUMENT SURVEY)AND 18 TO BE USED FOR MORTGAGE PURPOSES ONLY.
THEREFORE,THE OFFSETS AS SHOWN SHOULD NOT BE USED TO ESTABLISH PROPERTY LINES.
ESS EX COUNTY
DEED REFERENCE: PLAN REFERENCE: PLAN OF LAN
BK. SSS-1 PG. 145 PL.BKK 9?�� PL. IN
CERT.NO. -
BK. PG.
I hereby certify that the existing structures are located approximately as shown and PREPARED FOR:
were not in violation of the zoning by laws at the time of construction,or are exempt
from violation enforcement.action under,Chapter 40A Section 7 of the Mass.
General Laws.The structures are located in Zone G according to the following
F E.M.A.map.Note:Zone C represents areas of minimal flooding.
FLOOD HAZARD COMMUNITY NO 2500 M
BOUNDARY MAP NO,00086- EFFECTIV Z r4 9
SCALE IN.-40 FEET
r
THOMAS �� � BAILLIE & COMPANY
C. s
LAND SURVEYING & RESEARCH
8Arl LtE 33 HOWARD STREET
REGISTERED LAND SURVEYOR .t NOIX42
_ READING, MA 01867, ..
(ela PHONE (Z81)944 2767
DATE=�� ►;et FAX: (781):94'4=6112
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
************************APPLICANT FILLS OUT THIS SECTION*****"`*"******�`*'�***'`
APPLICANT /t�y�J�1-�1QLa, PHONE �e Iv (c 3
qq
LOCATION: Assessor's Map Number PARCEL d0 g
r r
SUBDIVISION LOT(S)
STREET ST. NUMBER 7Lf '
*****************************************OFFICIAL USE ONLY"********************** `*
REC MENDATIONS OF TOWN AGENTS:
J
ONSERVATION ADM STRATOR DATE APPROVED
DATE REJECTED f
COMMENTS ride,U. a4a- gjs — t�� �le, Q/ CO aefV-Aron—tO.')l ho
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD NSP CTOR-HEALTH DATE APPROVED
DATE REJECTED
NSPE OR-HEALTH DATE APPROVED t
DATE REJECTED
COMMENTS 'S �, swt aT lie e- - zavr�&L .rft `C ar.
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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4
d 1 X� gal/ Cf
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u e The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02919
'O+ sys y Workers'Compensation Insurance Affidavit
Name Please Print
----..tee
Name:
f 1
Location:
Ci to INA ,W Phone #
1 am a homeowner performing all work myself.
ED1 am a sole proprietor and have no one worldng in any capacity.
FI am an employer providing workers'c ompensaticln for my employees worldng on this job.
Company name: /^� h T•,� �h r/
Address -.9t>9 �V -it
City:
Insurance co. A -�-. ���.,�{ _ Pollex# W C 3 z
Company name. ,
.4cf�ir�ss:
Insurance Co. PbU -#
FaikWito,secure covers"as requiredd under section 26A or MGL tat carr leadtottre � P s of a fine art►to:tt,:
and/or one years'hnpr somrxxt-a9_vm 11 aseta floe-E j aria ag�,stme
understand that a copy of tins statement may be-Mrwarded to the Office of Irrresfigations of the MA for coverage
mon.
1016 hereby cerf�y under Bre palms and penalties of peowy that the/'k maabbrr praniided above is km and correct
Signature fi aln.✓ [ate li�-J
Print name 6re-4,vdon, SAA A/ Phrase �J�fG 3 4//,
7
Official use only do not write in this area to be cor VWW by city or town of xiar
City of Town Perrrd/ti. _
-
E� ,Btlttoint�
[10mwk Y kmnedbie,response is required
[.1LkWWnq B
" � SelectmalT's,
Contact person: Phone A I] Health Depar
Other
i
G
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
R disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
The debris will be disposed of in:
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
N2 1861 Date........ 1211.1
0 TOWN OF NORTH ANDOVER
Ui
S PERMIT FOR WIRING
�SSAAT.0
CHU
cc
This certifies that .........�—";Ao......C:�.. ..................................
has permission to perform ...........I ....... ..............
wiring in the building of...... i ..........
.........................................
at..... ....... 00.... ...............,,,-,North Andover,Mass.
Fee.. (AU. Lic.No ....... ........
LECTRICAL lNincmlt
X)
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
ThEECOM 10AW£r+ LTH0FAi .M(RU,SEM Office Use only!
1��11tT1Vi�VT'OFPl,�1l.ICSAFE'IY Permit No.
OFFRZE PREVEMONRE6MHONS527CMR12-00
FORWARD ttJ7Occupancy&Fees Checked
APPLICATTOIVFORPERMUTIJPRFORMELECMCN22:0t WO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE 2v SACHUSSTS ELECTRICAL CODE, W
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date
Town of North Andover To the Inspector of W ires:
The undersigned applies for a permit to perform the electrical work described below. P4AP PARCEL
Location(Street&Number) /
Owner or Tenant U
Owner's Address
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Purpose of Building t Utility Authorization No.
Existing Service Amps / Volts Overhead Underground No.of Meters
i
New Service Amps / Volts Overhead Underground No.of Meters
Ntber of Feeders and Ampacity
Location and Nature of Proposed Electrical Work 7 , C
No.of Lighting Outlets No.o£Hot Tubs No.of Transformers Total
KVA
No.of Lighting Fixtures Swimming Pool Above Below M Generators KVA
ground ground
No.of Receptacte 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
Pumps Tons KW Initiating Devices
No.JDiahwashcrt Space Area Heating KW No.of Sounding Devices
No.of Self Contained
Detection/Sounding Devices
NC Jf Dryers Heating Devices KW Local Municipal Other
Connccticna
No.of Water Heaters KW No.of No.of
Signs Bailasis
No_Hydro Massage Tubs No.iofMotors Total HP
OTHER•
i
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Ibawaamadliabkvhstaa=PbbymcL CaTfick ComaWoritsabstantaleg Aml YES ® NO
Ilya,estbnftEdwbdprcdcfsa,mtotlre0ffica YES NO F-1 T)uulmcdiad YES,*aseio k&thetypeofwxragptydridngdre
boxy/
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ee !aC C' IaoaseNa J �t�
Liter �. �ff/k `J �Vl� Sig mmL Limr=No �
- Hum2mTeLNo.Address-\15� C-�A
fC k-02 th AIL Td Na
OWNER'SINSURANCEWAIVER,Idoes mtImetbeirmrance aitss degz4cntasmg=d1�fMassadasetsGerma aws
anddArriy@grrahaeentnspam'appbmbmwai�thsreclmar�td \
(Please check one) Owner ® Agent O
Telephone No. PERIv'IIT FEE S
Signature ot Uwner or Agent