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Home My WebLink AboutMiscellaneous - 1600 OSGOOD STREET 4/30/2018 (86) 1600 Osgood Street Building#22 Location/4-,G-t�, No. Y? Date NORTq TOWN OF NORTH ANDOVER 9 i y Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s•►cNust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL Check #,/-o`le 18806 Building Insp6"or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING 's Section for Official Use Onl 4 . BUILDING PERMIT NUMBER: DATE ISSUED: ic SIGNATURE: Buildin Conunissioner/I or of Buildin Date <„ A 1.1 Property Address: 1.2 Assessors Map and Parcel Number: A;00 2 /' Map Number Parcel Number Di,�z 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS(ft) m Front Yard Side Yard Rear Yard Required Provide RcWired Provided R red Provided 1.7 Water Supply NiG.L.C.40.§54) ZO°e 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Outside Flood Zone ❑ 1 Municipal On Site Disposal System ❑ w' rilsionc is nct: Yes No 2.1 Owner of Record Name(Print) add�,sfb, ervice: Signature Telephone 2.2 Aghonzed Agent Name Print Address for Service: z Signature Telephone z M MIN MINNr 90 3.1 Licensed Construction Supervisor Not Applicable ❑ Address 9 ' �- -fes 40 Al C—) O License Number In� ,m- Licensed Construction Superviso.. E—xpira—tion'Date' Lo rgnature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M r Address r Expiration Date z Signature Telephone P^1 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 permit. Signed affidavit Attached Yea.......❑ No.......❑ s>�cxzort s MOO= ON sit�t ruff rc 5.1 Registered Architect: Name: i I Address Signature Telephone NOn- Name: rea Aof Responsibility Registration Number Address: Expiration Date Signature Total Not applicable ❑ Name: Address Registration Number Signature Telephone Expiration Date 4� Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Company Name: Not Applicable ❑ Responsible in Charge of Construction I New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: c � USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly 0 A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A4 ❑ A-5 0 1B ❑ B Business 0 2A 0 C Educational ❑ 2B 0 F Factory ❑ F-I 0 F-2 ❑ 2C ❑ H High Hazard 0 3A ❑ IInstitutional 0 I-1 ❑ I-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R residential 0 R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage 0 S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use 0 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area s Total Height ft n Independent Structural Engineering Structural Peer Review Rapired Yes ❑ No ❑ SECTION 10a Owner Authorization- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> as Owner of the subject property Hereby authorize to act on My behalf,in all matters relative two work authorized by this building permit application Signature of Owner Date t r � , Dia e I, f as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury p Print Name Signature of Owner/Agent ate Item Estimated Cost(Dollars)to be _ iv Completed by permit applicants, r _ sefiri 1. Building (a) Building Permit Fee Multiplier 2 Electrical /I- ac?- (b) Estimated Total Cost of 0 &f v Construction from(6) 3 Plumbing Building Permit fee (_)X(b) 4 Mechanical(HVAC) 1 5 Fire Protection I,% 1P is t L n+ Der►0 a aj C/. 10,M- 6 0M- 6 Total (1+2+3+4+5) �-� Check Number t�5�1�k S.,i#a i z.5s' �,. �!'�°;) 'y v(`°`^' fi :'3J� tt`k...✓zucnY�J ,.. r` v�Vii. 1xv r 7 h� A z" ffi �"r}� 3 .r- .:+..7�..L;,.,s. _.4 y ,- 4'd s .5 YS�r: N lq a.-0r '` ,1r �4Pz' :...r! 3.,'tC. :r. u{'w:t 1` .'�! n ,4..z..a: 1`,+��rr:•+�. <.,of ih%"�r ;��i. �e.'i�. a c°�s ,:m Z.a1;3.. 9 �"*'.sY-��4�>•r,�,t��",.tis .i,.,.r ..,5 Y fi5.r, rrr�?.r„zp�va�,k .i:t t' Ai <kN�* 7 ku f ,:` 13 #��fav 411' tf.,r{wsr .. 4 a� •,,�i .r h 3 v45 N 4 m r= vrtrr2 jt'-.14r7ii < YY.:i:9> NO.OF STORIES SME BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Y t yfi a '12 -11M d,# 15 �” ,3=p-{-.5 >•t"+er s �'a f .K a='. 3 �{ i '` K.�,?w s='" �- r '` �' s ,_ 1 -own ot Anctover No. 3 ?9 W. _ A = dover, Mass., COC MI CMEWICK �7S CO RATEO p � BOARD OF HEALTH PERMI D Food/Kitchen Septic System 1 J54�A BUILDING INSPECTOR THIS CERTIFIES THAT ...... ... ....................... ............................................................................................... Foundation has permission to a ct........................................ buildings n��w..................... Rough to be occupied as ................... chimney .................... .. ...... . ...................... provided that the person pting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the pro sions 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 CONSTRUCTI STARTS Rough " Service BUILDING°IN R. Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in. a Conspicuous-Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. J1ie v�anvnw� 4�Aaa sac��uae BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 048040 Birthdate:10/29/1955 Expires; 10/29/2007 Tr.no: 8053.0 a. i Restricted: 00 TADEUSZ DOWGIEERT 175 BRADY AVE SALEM, NH 03079 commissioner 1 rVKM U - LV 1 KCLCAQc rvr%m 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 127APPLICANT PHONE 7 / . 7 LOCATION: Assessors Map Number PARCEL SUBDIVISION_ LOT(S) STREET O flST. NUMBER OFFICIAL USE ON! RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT_& fc.,m 1+` f-C ' I/k 7ECEIVED BY BUILDING INSPECTOR DATE RGAW My JM 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 at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: CC (Location of Facility) J� Signature of Perm- it Applicant Fire Department Sign off: Dumpster Permit ate f Nov 08 05 09: 30a 6038900192 P. 1 FROM :ROBERTS INSURANCE FAX NO. :9786833147 Nov. 08 2005 10:44AM Pl/l ACORQ,. CERTIFICATE OF LIABILITY INSURANCE 3111 "' 200 1 8 005 PROouCER THS CERTIFICATE IS ISSUED AS A MATTER OF OWORMATION M.P. ROBERTS rKS. MMCY, INC. ONLY AND CONFERS NO RIGMTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE, DOES NOT AMEND, EXTEND OR 1060 OSGOOD STREET ALTER TME COVERAGE AFFORDED BY THE POLICIES BELOW. NORTR AM OVER, NA 01845 978-683-8073 INSURERS AFFORDING COVERAGE NAICM INSURED --- ..�.---• _.�..__.... -------- DOMGIERT CONSTRUCTION CONPANY INC. INSURER&�ESSEx INSURMICE COMPANY INSURER B: 175 BRADY AVL INSURER C: SALEM, mg 03079 INSURER O: OgARD INSURANCE GRORIP INSURER E: .—..._..— COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE WSUREO NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VWH RESPECT TO WMICH THIS CERT(FICATI MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDRIONS OF SUCH POLICIES,AGGREGATE LMTS SMOWN MAY HAVE BEEN REOUCEDBY PAID CLAIMS. N"LLTR E•_.-._.._.___ POLICY NUMBER '0'0 Y Ef E. IVi LITCY IRATI LIMITS - ._. filtANCE GBNERAL LIABILITY EACH OCCURRENCE 1 11000,000 COMMERCNLGENERAL UAWLITY PRE-MISEIUMNI/ancr)•.,_ = 50.000 CLAIMSMRDE rx-1 OCCUR MEDEXP(Alywwow�ml) 1 �► 3CP3614 10/26/05 10/26/06 PERSONA 4ADVMIAm c 1 p 1,_QQ.�000 ,._ GENCRAL AGORDGATE s 2,000,000 W-ML AGGREGATE LIMIT APPLES PER %IOOLICTS-CpNPAOP AGG S1,000,000 POLICYF_l PRO LOC AUTOMOBILE 11AtlILITY COMBINED SINGLE!LMR ANVAUTO ALL OWNEDAUTOB « SCHEDULED AUTOS BODILYINJURY $(PM Pwm) HIRED AUTOS eoaLr INJIJw er 1 NONOWNEDAUTOB (Peaoelam) _ .---.— PROPEnTv oAMACE (PsradikiM) DARN*LWALITY AUTO ONLY-EAACCIOENT IJ ANYOWTO OTNERTWW EAACC 1 AUTO ONLY. AGO 1 EXCESSANOWLLA( LIAfiLnIY FAN OCCURRENCE 1 OCCUR l l CI.A(MgMADE AGGREUNCE S OEOLOCTRMLE _ `- RR-MUTION I EMPLOYERSWORIMRSCONIVINIALIABILITY TONv�A -B_ X ANY PROrMETWARMEREJIECtI DOWC600548 10/26/05 10/26/06 E.L.EACM ACCIDENT c _ ,MLL 000 D EM �f�yel� 1 E-L DISEASE-EA PI S 500 000 SPfCft eoso. E.L.OISEASE-POLICYIIMIT t pp p00 OTHER DEftRPTIONOFOFERATMONSULOCATIONSIVDIK SU EXCLUSIONS ADDED BY ENDORSEMENT JSPECIALPROVISRUNS 2 CERTIFICATE HOLDER CANCELLATION OZLY PROPERTIES, LLC. "ULD ANY OF THE ADOVE DESCRIBED POUCEB Be L;AMMLL.A YNFORF THE OrInATION 5 IDUME'E PARK DATE TMEREOF,THE LSS(lwG INSURER TNLL ENDEAVOR 70 MAIL 10 DAYS WRITTi:N ANDOVER MR 01510 NOTICE TO THE CENRFICATF HOLOFA NAMED TO THE LEFT,BUT FAILUNt IO LK7 SO SMALL KVOSE NO ODLIGATION OR UAIMLITY OF ANY KOp UPON TIE NSURER,ITS AGENTS OR RE ATNF A RIEPAE 7AT ACOR025(200VDB) MACORO CORPORATION I NS 7778372 KIDDER BUILDING & WRECKING,. INC. 247 Main Street PLAISTOW, NEW HAMPSHIRE 03865 (603) 382-1422 Fax (603) 382-3697 DOWGIERT CONSTRUCTION PHONE SATE TO: 978-685-0306 2(15/2005 ATTENTION: TED DOWGIERT JOB NAME/LOCATION 8 DUNDEE PLACE CONSTRUCTION TRAILERS ANDOVER MA 01810 OSGOOD STREET NORTH ANDOVER, MA JOB NUMBER JOB PHONE We hereby submit specifications and estimates for: COMPLETE DEMOLITION OF MULTIPLE PORTABLE TRAILERS AT ABOVE. REFERENCED LOCATION. PRICE INCLUDES REMOVAL OF CONCRETE STACK SUPPORTS, SLOPE AND ROUGH GRADE DISTURBED AREA WITH EXISTING MATERIAL. ASPHALT TO BE LEFT BROOM SWEPT UPON COMPLETION. REMOVAL OF ALL RELATED DEBRIS TO AN APPROVED DISPOSAURECYCLING FACILITY. PRICE DOES NOT INCLUDE ANY SITE PREP., BACKFILL, COMPACTION OR ASPHALT PAVING REMOVAL. NOTIFICATION BY KBW. PERMIT BY GC. CUTTING, CAPPING, MARKING AND RELOCATION OF UTILITIES BY GC. FIRE AND POLICE DETAILS BY GC IF REQUIRED. SITE FENCING AND SECURITY BY GC. DUST AND EROSION CONTROL BY GC. PRICE IS BASED ON SALVAGE. KIDDER NOT RESPONSIBLE FOR TESTING, REMOVAL OR DISPOSAL OF ANY HAZARDOUS WASTE OR OIL TANKS. -ptpjRd ftwibiotjej4pge specifications,for the sum of: 26,350.00 Payment to be made as follows: dollars($ PAYMENT TERMS TO BE NEGOTIATED. IF PROPOSAL IS ACCEPTED, PLEASE SIGN AND RETURN COPY. THANK YOU. All material is guaranteed to be as specified.All work to be completed in a professional manner according to standard practices.Any alteration or deviation from above specifications Authorized �n involving extra costs will be executed only upon written orders,and will become an extra Signature (_� charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado,and other necessary insurance.Our Note:This proposal may be workers are fully covered by Worker's Compensation insurance. 45 withdrawn by us if not accepted within days. Acceptance of Proposal—The above pries,specifications and con- ditions are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance: Signature PRODUCT 13128M USE WITH 771 ENVELOPE NESS To Reorder.1-800-225-6380 or www.nebs.com PRINTED IN U.S.A. The Commonwealth of Massachusetts } •; Department of Industrial Accidents ;;' l Office of Investigations 600 Washington Street N Boston, MA 02111 c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 7,- Address: 6Z 6� City/State/Zip:��"Z/-- tng 4C."9 J Phone #: ��•`' i �� Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with J G 1-1 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. + E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:. Policy#or Self-ins. Lic. #:-10 1_1/�f z 1262 CY P Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compens tion 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 tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth 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. 1 do hereby ceder the pains and penalties of perjury tl at the information provided ab ve is true and correct. Si nature: Date: t f I Phone#: l 3— O/fic•ial 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-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 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 pen-nit/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 'owruBtJC3A1�B�Y , BQAIP[lOIFE�BpR6{�S1N/X)11y1P1�[/l'A17C�11�63�77C�t12� P°"Rdc tato. �✓SZJ OCCUP=q&Fen CMcked - APFOUCA71ONFOR PERK U70 PERFORM ELECTRICAL WORK Au WORK To at.Pt'MRMBD IN ACCORDANCe WM THe MASSACHUSSTS M-ECMXAL cone,327 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersiPed appHa for a permit to perforin the electric work described below. Location(Street d<Number) S Ud 7 ,S Owner or Tenant �'( �•t tea.C, Owner's Addtest dOV-t/t is this permit in conjunction with a building permit yesm No a (Check Appropriate Bois) Purpose of Building Utility Authorization No. Existing Service Amps Volta Overhad Und WOMW No.of Meters New Serdo Amp.../ � Vols Overhad U nderPouid No.of Meted Number of Feeders and Ampacity Location aid Nature of Proposed Electrical Work Q i I dN No.of U0ft oodw Na d Hot Tete No.d7teedbmwa Told No.Of i.labdq RUM Swbm dng Pad' AboaBebw � KVA KVA No.of Receptab OWW Na of 00 Burmn No.of Fly t}51dim softy two Na of swhcr ou bm No.d0ee Bun= Na of Renpo N0.of Air Carl. Tod FIRS ALARMS Na of Zama Tea No.of 06poeeb Na of Heat ToW TOW N&dDetecaae and pwo Tone KW Walks Dwicm •�•• Na of Dbbwulim Specs Arm Haft KW ML OfSONWhis DMae No.of s df No.of DryseHesdq Dedoee KW Loody4� °�0mdne Devion Muddpd L7 °"w No.of Weser Rectae KW Na of No,Of sign Bdwb No.Hydro Maop Tube Na of Moran TOW Hr c ( b4 aid M lttQ -5� � hinmeomwRUMIDdepowma Lade ItwsaamtlitEftTaaa Pbiq';rridrB ori &*ftW W 4h,2VE y� Iha�esublrtifbdvnidptod stmedNeO�YtB ASU1sAiK8 ryouhed7 ww 13 Oma Q rmdnddig Ne dw aWby WadaoSW D hpcftDaft Ra* E dValatf 9Vmdw%kr dp 0* fEMNAM r CGl f C [iamseNa LioefBallo Vi c503 3 3r&o1. Ue S- .e 4 l�im.'IhlNo, /- �-8, S- 2 0WTmWS1ZLRANMW Iamawe elluheliaQe �diei►aa� AkTdNa a rddamysivViemeipmnilsppicnim Iii °�Q or'k �° '"�e109�dbY1bl�Cfi�GmeelLaat (Please check one) Owner CT A SM Telephone No. ,F88 r--- .� .- 7 . �