Loading...
HomeMy WebLinkAboutMiscellaneous - 1600 OSGOOD STREET 4/30/2018 (7) 1(000 cosb�A BUILDING FILE2-k) r � Mark ..,, VC]rj theater compony Executive Producer Email: mark r c @actandover.com Mobil :978.476.604 Box Office: 978.276.9568 Website: c andover.com I p-,J4 I L The Commonwealth of Massachusetts City\Town of North Andover Certificate of Inspect on In accordance with 780 CMR, Chapter 1 (The Sixth Edition of the Massachusetts State Building Code) and Chapter 304 of the Acts of 2004 (an Act to further enhance fire and life safety), this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to ACT Theatre 1600-ACT14 Indentify property address including street number,name,city or town Certificate Located at Expiration December 2015 1600 Osgood Street-Building 34 Use Group 164 Auditorium Seating for Performance Allowable Classification(s) 76 Crew and Cast for Perfomances Occupant Load See Detail 120 Capacity for Workshop/Rehearsals Certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or, tampering with the contents of the certificate is strictly prohibited. Conditions of Temporary Use Name of Municipal A ew Melni s e Chief Name of Municipal Brian Leathe, Building Date of Fire Chief Building Commissioner Official Inspection December 15,2014 Signature of Municipal Signature of Municipal Date of Fire Chief Building Commissioner Issuance December 15,2014 /i Date...7....... l...y....... f � r• rl i; 1 7 OF 00RT#j TOWN OF NORTH ANDOVER 9 PERMIT FOR PLUMBING 8'B,CMUSE This certifies that......-:P..`..................�`e has permission to perform.c'2...la(. ? . .°)- -/v ,/e6 . ..................... plumbing in the buildings of ©Z / .40� ..................... ....................:............................................. y at.... �.�0 ..... . �............................4......... ..... .North Andover, Mass. Fee ....4 7 ....Lic. No. /a73 /a73 .......... . ........ .................................................................... �f�i¢�A,-I PLUMBING INSPECTOR Check* MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 01 p P J°f CITY �� MA DATE �� PERMIT# �i� JOBSITE ADDRESS OWNER'S NAME 1 A f• i t POWNER ADDRESS r / ✓_ I TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL Q PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:Elf PLANS SUBMITTED: YES© NO FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM f i � 1 ( _____� DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM f DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN _ _ _1 ___.._l ____ ____ _.__J ___.-_- ____._) .. ..._...f _.__. 1 .. __I ____{ 4 .-._---1 INTERCEPTOR(INTERIOR) f _..__( f i .._....__( _ 1 ___._i ____j ___._. _._..____( _.___.1 .._r_._._.f f _.._._i KITCHEN SINK f ___._...I --_.._ E 1= LAVATORY L221_l 1 ___1 f -. ROOF DRAIN SHOWER STALL U __—_I SERVICE/MOP SINK TOILET _f _J URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ i __J1 1 _. _I OTHER =— INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2�KN'O _ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY� OTHER TYPE OF INDEMNITY D BOND Q OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mas sachu tts Gene al Law ,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNE�GENT 01 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi all P rtinent provision of the Massachusetts State Plumbing Code and Chapter �1-42—of—the —General Laws. PLUMBER'S NAME . _ _ / h —LICENSE# d 0 I �! SIGNATURE MP© JP Q CORPORATION RJ PARTNERSHIP®#=LLC j COMPANY NAME /� G ; ADDRESS C-Cl CITY STATE ZIP O/583 TEL FAX --�CELL �EMAIL ----._.. — ---- - -- ---..__._. _ .._.. _ ... -_.... ....._! ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL IN/S;PECTIO NOT RR Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES f � a .. The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �� j� Please Print Ledbly Name(Business/Organization/Individual): /V l //�7 /'1/6 U ir T' � "j�e C Address:—6 CG City/State/Zip: L q C //P AC ( A4 1" Phone#:__ q O Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t I• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers' comp.insurance. g, E]Building addition [No workers' comp.insurance 5. ElWe are a corporation and its required.] officers have exercised they 10F]Electrical repairs or additions 3.❑ 1 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' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ke 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job 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 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. I do hereby certify under the pains and penalties of perjury 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: 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#: Instructions . andto eel. 111formation enation fox their emp Y to ers to provide workers' comp contract of hire,' ter 152 requires all emp erson in the service of another under arty ee is defined as ...every p Massachusetts General La em loy ,o or more pursuant to this statute,an P al entity,or any express or implied,oral or written." oration or other leg or the artnership,association,alxppTesentatives of a deceased employer, the leg employees. However the An employer is defined as"an individual rp. and including al entity,employingant of the a ed in a joint enterp or the occupant house of the foregoing eng g artnership,association or other leg or trustee of an individual'p three apartments and who resides therein, em 10 er." ceiver not more than enance,construction or repair e deemed to be an such dwelling y xe house having 10 ment b owner of a dwelling los poisons to do maint dwellinghouse of another who emp Y p all withhold the issuance or ilding appurtenant the shall not because of such emp sh or oil the grounds orbu agency also states that"every state or local licensing g s in the commonwe oyagelse for ulredy MGL chapter 152,§25C(6) operate a business ox to construct building e or exmit to op evidence of compliance with the insurance CON subdivisions shall table ev onwealth nor any of its p renewal of a license produced.accep Nance with the insurance applicanth GL c°haptex 152,§25CM states"Neither the comm ' 'one y, ante of public work until accea authority. dente of comp �.ddrtl erform enter into any contract for chapter e been presented to the contracting requirements of this chap °in situation and,if the boxes that apply to y Applicants davit completely,by checking vriththeir certificates)of - enation affidavit es and phone numbers)along to ees other than the please fill out the workers' comp name(s), address( ) ptnerships(LLP)with-no emp Y necessary,supply sub-contracComspameS(LLC)ox Limited pensity Department of Industrial f • 'h 'compensation insurance. lfhe LLC or LLP does ave should insurance. LimitedLlabl ' �edto carry workers be,submittedto t e affidavit s partners,are notreq n and date the affidavit. went of members or p is required• Be advised thatsAlsodbe sur to sig requested)not the Dep employees,a policy ccidents for confirmation of insurance° lication for the permit or license is being q abed to obtain a workers A that the app the law or if you are req anies should enter their Octo the city or town uestions regarding Self-insured comp be return You have any q numb, listed artment at the num Industrial Accidents• Should ° call the D op appropriate line COMP policy,please self-insurance license number on the provide a space at the bottom or Town Officials The Departmenthas p aiding the applicant. City rimed legibly. ou reg an applicant fete and p addition, ce of Investigations has to Contac y current please be,sure that ou affidavit t in the event the Offs ldavit indicating (city°T nse num year need only submit one aff e affidavit for y hCe .numb, whichwill be used as a reference number."all in of the, ermltl given y itllicense applications in any g . licant should write al be-Provided to the please be sure to fill the,ezxn e city or town may p de out each that must submit multiple necessary)and under"r°b Site Ad ped theapplicant th ation( new affidavit must be fill policy inform business ox commercial venture A copy e for future permits or licenses. A °fthe affidavit a as b on officially Permit not related to ancomplete this affidavit. town)-" roof that a valida license or IgOT applicant as'Proof said person is NOT required to compl uestions, . Owner or citizen is obtaining you have any 9, yea•,where a home own leaves etc.) enation and should y license or permit to burn our coop (i.e.a dog ou advance for y ations would like to thanky The Office of Investig ive us a call. please do not hesitate to g ben: telephone and fax num ch Pt€ ealthofassa�use s The Depa�ent's address, o�kW_ The CQ eclde>;?ts Department o£T-Industrial Office of InvestigatiaM 6.00,Wash n9011 Street BQst�n} 0211.1. - Tel.#617,727,4900 #61.7�12`T-774� -- w.Mass,govfcha Revised 5-26-05 ti " I : OMMONWEALTH OF MAa` H : SE NGAS. -,:I.:::F. . T'ER ". PLUMBf'#tS`«A 'D IS.SU;E;S; THE FOLLOW CNG`"LICENSE • L4L11SED A5 A. JOURNE'fMA 'pLUMB,E1 pMAGL I.AFtO JR Iz ... AFI 9 ABORN``'CT' ti , 0-113'8..;.:::: >i5> LEM A 0197 ....:..::.: ; ;COMMONWEALTH O ;fF MAS:SAiHUSETTS:;> < BOARb`OF ;:. PLUM B`E RS«"AND G AS F FT-tEat' ' .. I:S.S;UE:S<THE FOLLOW<i NG L I CENS :::. Lf €NSVD .AS.. A MASTER!P:•.LUMBE'R %fl €DETER J MAGLIARO JR � � x W N � ;z �w M O1 0 1. 1 5.-- Date..�9... . of NoarM,� TOWN OF NORTH ANDOVER o � PERMIT FOR WIRING ss�c►,us� This certifies that `S o .......................................................................................................................... �PCPSSo z�5 C�G� �c f5 Su 11..�c./ has permissionRo perform ......................................................... . ........................... ....... wiring in the building of../Y(p 7- I�� 4z-,— ...................................................................................................... at . .610 .. . `�' P.�`�Z. , orthAndover,Mass .............................. . Fee..&Q.. ........Lie7No./f.,3Z.. ./yV.-............ . . �J ............. . .. ...... . 17Z7,L ELE ICAL INSPECTOR 4Check#�,! �� `,�-77 CommonwealthM Official Use Only of Massachusetts Department of Fire Services Permit Number lo�7 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev.9/05 (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 in ink or type all information) Date:10/02/14 City or Town of-.North Andover To the inspector of Wires By this application the undersigned gives notice of their intention toerform the electrical work described below. Location(Street&number) 1640 Osgood Street Suite 1.02 �Q' 3 Owner or Tenant ACT Theater Company Telephone No. Owners Address Is this permit in conjunction with a building permit? YES 0 NO❑ (Check appropriate box) Purpose of building Remodel Utility Authorization No. Existing service 200 Amps 120/208 Volts Overhead❑ Underground❑X No.of meters Amps Volts Overhead❑ Underground❑ No.of meters Number of Feeders and Ampacity Location and nature of Proposed EleCtriLCal Work Add outlets and switches in new walls.Add ceiling recessed lighting lights.Fish in devices as necessary. Add su el.Add emergency lights COMPletion ofthefollowing table may be waived by the Ins ector of Wires No.of Recessed Luminaires No.of Ceil.-susp.(paddle)fans No of Total Transformers KVA No.of Luminaires Outlets No of Hot Tubs Generators KVA No.of Luminaires 6 Swimming Pool Above❑ Below❑ No.of Emergency Lighting Battery units No.df Receptacle Outlets 15 No.of Oil Burners Fire Alarms Number of zones No.of Switches 4 No.of Gas Burners No.of Detection and Initiating devices No.of Ranges No.of Air Total No.of Alerting Devices Cond. tons No.of Waste Disposers Heat pump Number Tons KW No.of Self Contained Detection/Alertin No.of Dishwashers Space/Area heating KW Local ElMunicipal Other connection 11 No.of Dryers Heating Appliances KW Security Systems:* No.of devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters signs Ballasts No.of devices or Equivalent No.Hydro massage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of devices or Equivalent 'Other Add electrical sub panel Insurance Coverage:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee sprovides proof of liability insurance including"completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. Check One: Insurance❑X Bond ❑ Other (Spec): 2/18/15 Estimated Value of Electrical Work $3,000.00 (When required by municipal policy) (Expiration Date) Work to Start: 10/04/14 Inspections to be requested in accordance with MEC rule 10.And upon completion. I certify,under the pains and penalties of perjury that the information on this application is true and complete. Firm Name: Allstate Power&Control,IncLic.No.:A17425 Licensee: Michael DeCristoforo Signature:_A0 Lic.No.:E18092 (If applicable,enter"exempt"in the license number line) Bus.Tel..No.:781-3164967 Address: 2204 Pheasant Creek Lane Peabody,MA 01960 Alt. Tel..No.:978-587-3593 * Security System Contractor License required for this work:If applicable,enter license number here Lic.No.: Owner's Insurance waiver:I am aware that the licensee does not have the liability coverage I am the(check one)Owner❑Owner's Agent normally required by law.By my signature below I hereby waive this requirement Owner/Agent Telephone `i ^ Signature Permit Fee: I l ��d4 71- A�U® CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDNYYY) •�' �....� 10/3/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER .CT Robert Abraham FAX Amity Insurance Agency, Inc. WL.E,,, (617)471-1220 PHON _(617)479-5147 500 Victory Rd. AFt)MpAgILEwRabraham@amityins.com Marina Bay INSURERS) AFFORDING COVERAGE NAIC 0 North Quincy MA 02171 INSURERA:Travelers Cas Ins Co of Am 19046 INSURED INSURERB:Hartford Fire Ins. Co. 19682 All State Power & Controls Inc INSURER C: 2204 Pheasant Creek Lane INSURER D: INSURER E: JPeabody MA 01960 1 INSURER F: COVERAGES CERTIFICATE NUMBER ter 14-15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LBR TYPEOFNSURANCE POLICY NUMBER POIDON11 F POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 $ COMMERCIAL GENERAL LIABILITY PREMISES Ea RENTED $ 300,000 A CLAIMS-MADE F—x1 OCCUR 680605OP466 /25/2014 /25/2015 MED EXP(Any one Moon) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 X POLICY JFrT PRO- LOC $ A AUMOINLE LIABILITY COMB SINGLE LIMIT TO11000,000 ANYAUTO 680605OP466 /25/2014 /25/2015 BODILY INJURY(per person) $ ALLOSMMED AVTOSSCHIEDULED BODILY INJURY(Per accident) $ 8 HIRED AUTOS X AUTOS ED PPer acle ,Dft,AMAGE $ S UMBRELLA LIASOCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION S $ B WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITYTORY LIMITS ER ANY PROPRIErOPJP� YIN EL EACH ACCIDENT S 500,000 OFFICERIMEMBER EXCLUDED? ED NIA (Mandatory In NH) DSVECLD4603 /18/2014 /18/2015 EL DISEASE-EAEMPLOYEE S 500,000 1/yes,descrile under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Ranarks Schedule,N mora apace 1s required) Electrical contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Fallon Carey/FND ACORD 26(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS026 potoos).a The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Deparinrent oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wivw.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Levibiv Name(Businesslorga&ation/individual): A w, A"A C 1 O4ytv tir eowy t2 o L Addt=: 220 V-%C--4.rAwv QjzgcV, `- ANE City/StateM z A V10 —g t G Phone#: S 8 — s'q 3 Are you an employer?Check the appropriate box: Type of project(required): 1.[ff I am a employer with 3 4. ❑ I am a general contractor and I employoes(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.inauance comp. ranca.= 9. ❑Building addition require&] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. officers have exercised their I am a homeowner doing a!1 work 11.Q Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12. Roof airs insurance required.]t c.152,§1(4),and we have no 0 employees.[No workers' 13.0 Other comp.insurance required.] `My aPp that d w&lrwr A tnua stso fill out the section below showing their waiters'compensation policy infmrnatkxL t ,my qW nes vlw submit phis of idavit indicating dhey are doing all work and that hire outside contractors must submit a new atrdavit indicating such. :Ca mctas that check this bot mash attachod on additional shoo slowing the num of the n6vaaaactas and state whether or not those emititx have en ployeeL if the mbcow�have anployces,they mast provide their workers'cwqt policynumber I am an employer that is protdding workers'compensation insurance for my employeeL Below is the policy and Job site informr dem Insurance Company Name:_ Foq.b Policy#or Scdf--ins.Lie.#: 096 w V=—C• LbYGLZ Expiration Date: 2/�1�_ Job Site Address,,—/ -�L � ,— CitylStateJZip:MorAll Alyb 0Ul �r MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of MGL G 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 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 fast wce coverage vtriGeation. I do hereby7=:��= information provided above is true and comet Si Date: Phone#: 9► t� 15' - ~S 3 Opdal use only. Do not write in this area,to be completed by city or town offldaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffewn perk 4.Electrical Inspector S.Plumbing Inspector to Other Contact Person: Phone#: 1 �'-7'ASSACA `SETTS - RIVEEFirS LICENSE r`t 111-04-2013 NONE ,� NONE S05OW 4bEV-tos '11-11=194 ' NONE '"A"3 r• ,s atx M r xsr s =fxISTOFOR0 MICHAEL a 2701 PHEASANT CREEK PEASM.MA 01M COMMONWEALTH OF MASSACHUSETTS i 80ARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENS ' AS A REG JOURNEYMAN ELECTRICI MICHAEL DECRISTOF ORO . 1a 2204 PHEASANT CREEK LANE TEABODY MA 01960-4751 1$0 2 E 07/31!16 10416 wma�'t�prt^,,�da:[. �;iiC7f;7 • •. ,c t COMMONWEALTH OF MASSACHUSETTS BOARD OF ELECTRICIANS ISSUES THE..FOLLOWING LICENSE AS REGISTERED MASTER ELECTRICIAN - p 1 ALL=STATE POWER. AND CONTROLS INC ' MICHAEL DECRISTOFORO 2204 PHEASANT CREEK. LN �:PEABODII r ;,FIA 41960-4751 • -17425 A 47 31I 1& : 70417