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HomeMy WebLinkAboutMiscellaneous - 1620 SALEM STREET 4/30/2018 1620 SALEM STREET T 210/1068 0000.0 - - - - --- Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACHUS ...................... ........................ This certifies ...... ...... has permission to perform ............. ......... ........... ............. wiring in the building of........ ............................................... at ..............n... North Andover,Mass. FeeLic.No....1k 0 .............. ..................I......... ........... 'ELECTRICAL INSPECTOR Check # 9258 2012 Massachusetts Electrical Code Amendments 527 CM)112.00§Rule S: In accordance with the provisions of M.G.L,c.143,§,3L,the d 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.01 c. 166,§32,an electrical permit shall he issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification o£completion of the work as required in M.G.L.c.143,§3L. r Permits shall be limited as to the time of ongoing construction.activity,and maybe,deemed_bythe.Jnsp.ector_of_Wires abandoned.and.invalid-if-he— or she has determined that the authorized work has not commencecror has nvg-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 23 8 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 ofreal property.With limited exceptions,the Act automatically dxtends,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 extendingthrough August 15,2012. rulePermit/Date Closed: Note:Reapply for new per ❑Permit Extension Act—Fermi/Date Closed: ecco--nzPwnwea&o f VaMachu-leff3 Official Use Only _�*� el Je aPfinenf oiPe�ervice� Permit N©. / 0-4 Ej Occupancy and Fee Checked c3o --- 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 tl:e Massacbusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: "Z \\ S \ p City or Town of. ' )or1jan" A h o Y Q..r 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) �_'Z,t� 5�\Q`M Sal Parcel ID: Owner or Tenant �pyl o"1 a, Qr -X N a Telephone No.°\-) Owner's Address Sv&Lyn S Is this permit in conjunction with a building permit? lyes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:��e`gCQ RW Completion of the followin table may be waived by the Ins ector 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 No.of Luminaires Swimming Pool Above ❑ In- ® o.o Emergency Lighting rnd. rnd. $attea Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices { No.of Waste Disposers Heat Pump Npffib�e.- Toffs -- Kir No.of Self-Contained p Totals: - - - Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* r3 No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Sians Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total IIP TelecommunicationsNoDeicer Wiring: No.of Devices or Equivalent OTHER: 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: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) \ I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: M wx L.14,-n oyZA,�SZ -Signature-%" LIC.NO.: (If applicable,enter `exempt"in the license number line.) Bus,Tel,No..±Nlz 0-a'3\ 7 a Address: \ W \\ nqmh:ka n Z..onc-A n Alt.Tel.No. i R 3°!1 �'^t 1 *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 by law. By my signature below,I hereby waive this the(-h,•c1-one)❑owner ❑owner's ac ent. Signature Telephone No, �ER1 I.I r Date.A-I�....�-H...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................................................... 4-) ............ has permission for gas installation 7,5,6 ........................................................... in the buildings of............................... /at... U ... ............... North Andover, Mass. Fee ............... Lic. No. .......................... .................................................................... GASINSPECTOR Check#/7? 9240 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: NORTH ANDOVER MA. DATE: 01/16/2014 PERMITPZ�Q - ' JOBSITE ADDRESS: 1620 TURNPIKE ST OWNER'S NAME: TO RENTAL LLC GOWNER ADDRESS: Q 1 *:tNC TEL: 978-794-1400 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED:YES ❑NO ❑ APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES P-1 NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT x I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all Pertinent provisions v of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. PLUMBERlGASFITTER NAMZ ✓LICENSE# 5'3_3 SIGNATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP:01844 FAX:978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFO@OSTERMANGAS.COM MASTER❑JOURNEYMAN ❑LP INSTALLER CORPORATION ❑# PARTNERSHIP ❑# LLC ❑ #45-326-3311 pai- ry U T / ® DATE(MMIDDNYYY) AC� � CERTIFICATE OF LIABILITY INSURANCE 6/26/2013 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 OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)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 NAMEACT Angela Bacon Cutler Segerstrom Insurance Agency PHONE . (209)532-6951 I FAX No):(209)532-1997 License #0495772 ADDDDRESS:angelab@cutseg.com 1030 Greenley Rd. INSURERS AFFORDING COVERAGE NAIc# Sonora CA 95370 INSURERAAS en Specialty INSURED INSURER B AI G Osterman Propane, LLC INSURERC: P.O. BOX 29 INSURERD: INSURER E: Whitinsville MA 01588 1 INSURER F: COVERAGES CERTIFICATE NUMBER Osterman 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. INSR ADDL SU POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER M/DDNYYY) (MMIDDIYYM LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 AMAGE TO X COMMERCIAL GENERAL LIABILITY PREM SES Ea o=ante $ 2,000,000 A I CLAIMS-MADEFZ OCCUR 00113 6/30/2013 6/30/2014 MED EXP(Any one person) $ 100,000 PERSONAL SADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMfr Ea accident 2,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 954068 6/30/2013 6/30/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOSq —NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC S.RyTATU- OTH- AND EMPLOYERS'LIABILITY Y I N FR ANY PROPRIETOR(PARTNER/EXECUTIVEF7 N/A EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space is required) 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. 146 Main Street North Andover, MA 01842 AUTHORIZED REPRESENTATIVE Pete Kleinert/ANGELA ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD The Commonwealth ofNlassachusetts - Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl UU � Y Name(Business/Organizationlhdividual):CC 62ST Address -57 City/State/Zip: !`,� UCzJ _/�ll�' eMzll Phone#: Are,you an employer?Check the appropriate box: Type of project(required): 1.Il✓I'1 amuaa 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. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. [1We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I 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.❑Roofrepairs insurance required.]i 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. 7'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:,/ - 4,ke -: 6;�,L4T, Policy#or Self-ins.Lie.#: /5�$ ,f37,75` Expiration Date: lie)II Job Site Address:zl ,��,edj -3� 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 flue 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 certo under the gins and penalties ofperjury that the information provided above is true and correct. Simiature, Date: ! l Phone#: —900 -3 6 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#: SACIUSETTS>., COMMERCIAL - DRIVER'S LICENSE 114W 71�y ddN"kI R x $09256764: f ie Elm 5 ooe`" 1 :11 15��k lfio: r issor`M�, 11mr`5-0B Mal-A e 8ARBOR CT LYNN;MA'01902.1110 G� 'b% ✓ r5 oU 11.1&203 Rev 07.15-2009 i UPJtBERS ANG :. .�.•:•� :.. -lCENSED AS AN LP G SFlI T S ISSUES THE A6OVE LICEAS }O: L,LE}� ro: :PIXCNAEL A BRYSON SR a ARBOR CT '4 LYNN }'IA 111902-I l i p ` 93,, p5/pI/,14 • 768yp� . i 1 GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: 1 PHONE NUMBER: i ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL tz)ex3 Date?` .. <"OTPI TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING s o� 1 z This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform i plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at/.��,. . . . .. . . . . . . . . . . . . . . ., North Andover, Mass. Fee�. . . . . . .Lic. No../� . . . . . . . .'. . . . . . . . . . PLU B GINSPECTOR Check # 8503 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING bC� CitylTown. ae- 1 h oV ft,`r , MA. Dater S \O Permit# 5`0S ' Building Location:\ -CQ SA Owners Name: V"► 1 C + Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ] New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ® Plans Submitted: Yes❑ No LA —7 6 FIXTURES z z O Y U t— U) Q z Z 0 N 2 a w V) ~ W Z to Y c� -1 o- X -i m U. Q w o 1-- z ce o 9 W z 0 0 O v a u. w v U) iL o n � h > > 0 0 o z ? N W W = � Q Q F- a m m o o u. O x Y to to 1— n O SUB BSMT. BASEMENT 1 FLOOR 2 NLFLOOR 3 FLOOR 4 FLOOR 5FLOOR 6 FLOOR VH FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name:G'��� ��11�tK��e>ti� _ 1 de ®Corporation � i Address:SSE> >WAC`»(������ City/Town�� EG" `�3 State.)V N ❑ Partnership Bv;Sinebs Tel t"�ra�X19 wt'-Al Fax: L tt ❑ Firm/Company Npme of Licensed Plumber: 41 I,CV �x,ngrn INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes® No❑ If you have checked YJ please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner ❑ Agent 1 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ®Plumber Signature o Licensed Plumber City/Town ©Master APPROVED OFFICE USE ONLY ❑Journeyman License Number.- =«l_�JJ► -.: R ..ie!.iV'uw.«ws Y '.w:Rb ' ,ry}±;nig*{�yry9�v+weMM'° R,+,�rc�A&=uYYi�"r"•<�'w�4flatlr s+.ryw.#S--�y'2ti.'�b*^Mt�w.HNtW"Ywaryv.u..uc &Wu`+�„,ye`�33 a�+�+�^ `SLa td�M+�.aB �• s.s<, :.. 'RrvC'a-'1 .w �, �'•.. r°`�r�e Lig _ �aA9i^^.mO?t tl wtis +9 'ma.' rtawru "'r. FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS) 1 • k /1 t FEE: $ PERMIT# ,fat APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING r, 1 LOCATION OF BUILDING SKETCH PLUMBER LICENSE NUMBER: PERMIT GRANTED DATE: PLUMBING INSPECTIOR Z NAP 2917 Date.... �!. ..1..... �, f NORTH 1 0- TOWN OF NORTH ANDOVER « . PERMIT FOR WIRING sACNU'- This certifies that u `� �= C ........... ............... . ................................................................ liespermission to perform i�ct t� S ring in the building of............(,r-..!-+L ........................................... �`v �' /�`�' S 7 North Andover. Mass. at......... .................................... .y........................ Fee........... ... Lic.No. r�...... i�................�- �....�a0-n... ELECTRICAL/INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Official Use Only Permit No. 0;7?"SSXe WS,57'7.5 ae�Cmt+ue�rt o��u�ftc Sa6euy Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 9MR :00 (Please Print in ink or type all information) Date J Y G To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work desc;bed below. Location(Street&Number (fJZ J �� S� Owner or Tenant_ Don CU( Owner's Address S,fjY� Is this permit in conjunction with a building permit l Yes ❑ No Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgrnd ❑ No.of Meters New Service Amps Voits Overhead ❑ Undgrnd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorkLX - 411 Total i.o.of Lighting Outlets No.of Hot fuse No.of Transformers KVA No.of Lighting Fixtures Above ❑ In ❑ 9 9 Swimmin Pool Swimming grnd ❑ grnd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di osal No. Pum s .Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other moN.o.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Si ns Bailases Wirin No.Hydro Massage Tuds, No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If y checked pI a indi ate the type of cov agAbohecking the appropriate box. INSURANCE = BOND = OTHER = (Please Specify) (//%( � X—1—7, �31 Estimated Value of Electrical Work$ (Expiration ate) Work to Start Inspection Da Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME tJ G LIC.NO. s Licensee5-C _ , `em _JU Signature Ib� LIC.NO. ALA�, us.Tel No.Address V U v �Glt Tel.No. OWNER'S INSURANCE WAIVER: I am aware thatLi en ses does not havethe' e insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) �rI (Signature of Owner or Agent) Telephone No. PERMITTEE $ �V