HomeMy WebLinkAboutMiscellaneous - 165 MILL ROAD 4/30/2018 (2) 165 MILL ROAD
210/107.60070-0000.0
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Date..........e
NORrry
OF
c?; TOWN OF NORTH ANDOVER
* PERMIT FOR WIRING
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This certifies that ..........
I`r
has permission to perform ... ...... ..
, .......... ............!.......................................................
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wiringin the building of................................. ...............................................................
` at .....:!.�.............t......!...! .. rt... ......:.....:North Andover,Mass.
................. ...... � - �
a ELECTRICAL INSPECTOR
-- a .. .
F I
Check#
_ Official,Use Only
Commonwealth of Massachusetts
Z� l
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (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 INMK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his r her intentio to perform the electrical work described below.
Location(Street&Number) n
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building_ Mry l.. 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:
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Cc1 Susp.(Paddle)Fans No.of Total
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. Battery 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
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers.- Heat Pump Number Tons KW 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:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
'a No.Hydromassage Bathtubs
rNo.of Motors Total HP Telecommunications
of Devices or Equivalent
OTHER:
����..,tt .�/"Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (/c✓ (When required by municipal policy.)
Work to Start: - , V-vt 17 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 El BOND ❑ OTHER ❑ (Specify:)
X certify,tinder the ins and penaltieso perjury,that the information on this application is true and complete.
FIRM NAME: - �4 3 LIC.NO.: �
Licensee: �Wp,iL_ Signature -LIC.NO.:
I a licable enter exem t"in the license number lin
(,f� Pp p Bus.Tel.No.:
Address: 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/Ag ent
,�.
Signature Telephone No. PERMIT FEE: $ ,5
❑ 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 J
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 M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date: ,
SERVICE INSPECTION:
Pass Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Y
Inspectors Signature: Date:
8�
ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPEC ON:
Pass IN V Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: 146 �,��''�� Date: G Lf - 1,
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
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.- The Commonwealth of Massachusetts
Department of IndustrialAccidents
tl I Congress Street,Suite 100
Boston,MA 02114-2017
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www mass.gov/dia
•Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/
Individual): C.�i'l (� C
Address: Zi�
City/State/Zip: ,'J0 Phone#: 7q 770,U (//!
Are you an ern p oyer?theck the appropriate box: Type of project(required):
1.❑I am employer with employees(full and/or part-time).* 7. ❑New construction
2. a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.[__jI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
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.Lic.#: 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify and r thepains and p naIti ofperjury that the information provided above is trueandco nd rect.
Signature: Date: L b� t
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#:
i
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 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 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 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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IMPORT CONTROL# 0065
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pplication at amt �e;fo if your license is lost,damaged
and any other mailing of y R g dM for needs to be corrected,visit our web
site atrma§s.goviag
erierval s instructions to ensure the proper malting of your Rene j=
This Ii ence.
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egulations.Your usetts
assigned toPerson or a Privilege,and cannot be and � . to Massachusetts General Lav-s
regulation license onu pe►son°r and
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required �'Keep this . signed to any person or erift under pen y Of s `" -
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Locationz�
No. ITS'S7 Date
MORTh TOWN OF NORTH AN-DOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
' Foundation Permit Fee $
Other Permit Fee $ s
TOTAL $
Check # / 411
15 5 3R
1 'Buildin nspector
T0VyT;izz�F�NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
. --'- , "t'u,Y CHs �� �...,,��"� . _,,:: �,� l�` iJ��, "' ;,� v ..�:• &� �a,
BUILDING PERMIT NUMBER ��� DATE ISSUED:
�l ic
SIGNATURE: ..�
Building Commissioner/Inspector of Buildings Date Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
16 s Nli« 4K
a A 6:;C �v
QMD0 V/6'IC 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
Fronf'Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: !, 1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
DA V1 t40JT 141Lt— cS4
Nagle(Print) Address for Service
nature f j� Telephone
2.2 Owner bfkecord: j
A-M 6- O
Name Print Address for Service: z
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: n ��
6 O
'-4(\J �V I 0(J License Number Mn
Address3� S a 3 �
Expiration Date
Signature ,n Telephone
G 1-h-L
3.2 Registered Home Improvement ContKctor Not Applicable ❑
Company Name ����a�
"36-3 / O� S A}� � O S Registration Number r
Addr ss C�` ��+
Expiration Date `^
Si nature Telephone V 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 permit.
Signed affidavit Attached Yes.......0 No.......❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building�9Repair(s) ❑ Alterations(s) C�Z_ Addition ❑
Accessory Bldg. ❑ Demolition cW= Other ❑ Specify
Brief Description of Proposed Work: L
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2eVVVe_ IQ,Ad beAPiA; f,JJ A4,d rr�l Ce w jA&--I be,
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFkTCIAL'USE ONLY _= °
Completed b permit a licMR
ant
c
1. Building (a) Building Permit Fee
20, o v o Multiplier
2 Electrical e o U (b) Estimated Total Cost of
Construction
3 Plumbing o Building Permit fee(a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Uva Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, t) Ar,'3 as Owner/Authorized Agent of subject property
Hereby e to act on
My calf,V all arffters re ative to work authorized by this building permit application.
n Z
Sin re of Date
ECTION 7b nnOWNER/AUTHORIZED AGENT DECLARATION
I, �° t4 P J 1 Y(i4r",,i 2 ,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
Si ature of Owner ent Date
Y
NO.OF STORIES SIZE •
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 3
SPAN
DIN ENSIONS OF SILLS
DIN ENSIONS OF POSTS
DMENSIONS OF GIRDERS
—HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CH]A4NEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Proposal
James Construction
353 Grove Street
Melrose MA 02176
Phone 781-665-4112
Proposal submitted to: Dave and Jen Hought Phone#:
Street Address: 165 Mill Rd. Date:
City, State&Zip Code: N.Andover MA Job Location: Mill St
We hereby submit specifications and estimates for kitchen/bath/family room:
• Demo existing kitchen and bath down to studs
• Demo kitchen floor down to sub-floor
• Install temporary jacks on both sides of wall to be removed and demo wall
• Install pocket beams,cut ceiling joists and install new structural beam
• Install new header into dining room to expand opening
• Frame new bathroom with closet
• Frame for new window installation(new location over kitchen sink)
• Frame for new bay window
• Install new windows and install rubber membrane flashing
• Relocate plumbing in new bath,kitchen sink and stove
• Rough in new electrical for recessed lighting,outlets where necessary and under cabinet
• Relocate heat(possible toe kick in kitchen)
• Insulate exterior walls where necessary
• Hang blueboard and provide plasterer(TV room and living room ceilings)
• Install tile floor over plywood and cement backer board
• Install kitchen cabinets with crown molding
• Provide installation of granite countertops
• Install tile for backsplash in kitchen and bath floor
• , Install combination wall unit with granite surround(entertainment center,mantel and shelving)
• Countertops on cabinets in wall unit to be wood
• Install crown molding on unit
• Provide finish plumbing and electrical
• Install interior trim(baseboard and casing)
Cost: $29,000.00
Please contact me with any further questions you may have concerning this proposal.
All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviation
from above specifications involving additional cost will become an extra charge over and beyond the estimate.
Our workers are covered by workman's compensation.
a
Authorized Signature:
Note:This proposal may be withdrawn by us if not accepted within 30 days.
Date of Acceptance: Customer Si nature:
-
`
The Common l
wea -h of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02919
Workers'Compensation Insurance Affidavit
IN Please Print
loam
Name: Ail CAn/S7fZu Lilo
Location:
Ci U. lowyCZ
I Phone �
am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
f am an employer oyer 0 providing workers compensation for my employees workingon this 'o job.
Comaame name:
Address
city: Phong
I-insurance Co.
pollcv
QompM-name:
Address
Cltv:.
Phone*
nsura cze Q.
off
Pasture to secure penalties.of a fine up to s1,50().pp
I coverage as required under section 25A or MGL 1,5,2 carr tee�t to the i►><tpoesr�ton d exirrrinal
and/or one years'imprisonment as welt as c3W penalties in the form of a sl'oP wow Otic EA and a fire tael($10p tom)a day against rne. t
understand that a copy of this statement maybe forwarded to the Office of invesfigabons of.the piq for coverage vertficatiion
/do herby certify under the ains and penalties of
perf ury Mat"inlatnation provioed above is true ami correct
I
Signature/2
Date
Print name �RIJ AA6-012E
Phone# �� (o &5 •411 Z
Official use ony do not write in this area to be completed by city or town official• 0. Building Dept
pGheck Yimmediate response is requked Building Dept I] Licensing BOalt/
D Selectman's Office?
Contact person. Phone#- 0 Health Department
Other
4M WORKMAN'S COMPE'NSATIOM
• -C�6'�ILY/2097fIlP.CLLLiL C �!GGfL:kXL''/ je" 4 _
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PBOARQ OF-BUILDING REGULATIONS .'
` Lacense: CONSTRUCTION SUPERVISOR_
3Number: CS 07.5392
+Birthdate:05/24/1964
Expires:05/24/2003 Tr.no: 75392
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353 GROVE ST r <9 ' (.�•.� ! ,
MELROSE, MA 02176_i'---- Fr Administrator
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JAMES CONSTRUOTtON
JOHN MAGUIRE
353 GROVE ST.
MEL-ROSE,MA 021V6
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NOTE; PERSPECTIVE DRAWINGS REPRESENT THE ARTISTS INTERPRETATION OF THE GENERAL NO?E: ALL DIMENSIONS GIVEN ARE SUBJECT TO JOB SITE VERIFICATION&
APPEARANCE OF THE ROOM&ARE NOT INTENDED TO BE A PRECISE DEPICTION. ADJUSTMENT TO FIT JOB SITE CONDITIONS.
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OF ROOM&ARE NOTINTENDED TO BE A PRECISE DEPICTION. ADJUSTMENT •FIT JOB SITE CONDITIONS.
NORTH
E Town of dover
o� --' LCHIV � dover, Mass., v�
ADR11-
ATED P'Q�\
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT........ V ......... ...0.............................................................................................. Foundation
has permission to erect.. A'.1�V.............. buildings on ....1.46..�....MAY.......&Reo' ., Rough
to be occupied as /l 0AI t Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. A w? C/490 PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
. .. ............................................. Rough
..... . . ............................
Service
BUILDING INSPECTOR
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.
PERli1T NO. / PAGE 1
APPLIUTION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
w MAP "O./o 7 LOT NO. od Z® 2 RECORD OF OWNERSHIP DATE BOOK iPAGE
ZONE I SUB DIV. LOT NO. F 1
LOCATION //� �/ PURPOSE OF BUILDING
OWNER'S NAME(��� �l/tt7NO. OF STORIES SIZE
OWNER'S ADDRESS �� G�'L BASEMENT OR SLAB '
ARCHITECT'S NAME SIZE OF FLOOR TIMtERS IST 2ND 3RD
■UILDER'S NAME SPAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET - - POSTS
DISTANCE FROM LOT LINES -SIDES REAR GIRDERS
i
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
If BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL SUILDING.CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
If BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS L � �� �)t� � ,�'^/�� 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDESn
J/ (<zLg CST. BLDG. COST
f9d ��Q� L/" T..
PAGE 1 FILL OUT SECTIONS 1 3 EST. BLDG. COST FIER SQ.. 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
I
DATE FILED /,�,
si1LDINa INSPS:CTOR
SIGNATURE OF OWNER OR AUTHORIZED AGENT
f E ETu OWNER TEL/
S[AMIT ORANT[D 'CONMTEL# 7"': -'ff?O
-19
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1 V - BOARD OF HEALTH',
Food/Kitchen
Septic System
cc •lnlBUILDING INSPECTOR
THIS CERTIFIES THAT....................5. 4kzt ...:......................................................................................................... Foundation
has permission to erect.....At...1?.k.... ...... buildings on......../....�.�..�!!!.�.`�....AR.. ..................................... Rough
to be occupied as........ s�! i!!! C. .�l`4�t�%. ................... ................ .ff ze� 71YYg....... A. . Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions 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
UNLESS CONSTRUCTION TARTS ELECTRICAL INSPECTOR
Rough
..........::......... ................ Of
.. -- Service
DING INSPECTOR
- 40 Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a: Conspicuous.Place,on, the Premises Do, Not Remove Rough
Final
No:- Cathing,e,or Dry,Wall To Be Done
• FIRE DEPARTMENT
Unti Inspected and Approved= b the Bulldog Inspector.
Street No
s ',� s' s.:....y ,t..• ,i „e. ��'s �; ;^� .�N,.tF .,, y•a#.sgs.. ,�+-_•, ss.'° - _'z.. -, t r:-:. s - _ _ _ -
-
_.rs,. � =�:.� a,•^..a r-f, 4 Y - P
-
„s-
Y
_
,
-
No 2076 Date..
Ot NO oTM Ati
3: ��,r�` +•'e�O� TOWN OF NORTH ANDOVER
- p PERMIT FOR WIRING
;,SSACMUSE�
This certifies that ..Al.t.77...........acc.......................................
has permission to perform '
wiring in the building of......... W/Q..�..�.Z...............................................
a at.......f k...� ........ '!.!..��...h'�'!..'.................. ..... .North Andover;Mass.
f� . .......Fee,M.'I.W... Lic.No. ......<.........................
ELECTRICAL INSPECTOR
coo ova
WHITE: Applicant CANARY: Building Dept- PINK:Treasurer
� +
Office Use Only -7,
�I�e (�ommonwetxltli ofItteBaci�i��efts Permit No.
Bepartment of Public bafetg Occupancy A Fee Checked
3M Peeve blank)
BOARD OF FiRIt 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 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFO MATION) Date
City or Town of 1" f X� Lam' To the In of fres:
The udersigned applies for a permit to perform the electrical work described below.
v
Location (Street S Number) r_ �L _
Owner or Tenant ! I) /2 v 2
Ovinar'3 Address
Is this permit in conjunction with q building permit: Yes ❑ No til (Check Appropriate Boz)
Purpose of Building UtI ity Authorization No.
Existing Service _Amps_1 Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps_J Volts Overhead ❑ Undgmd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No.of Ttanstormers Total
No.of Lighting Outlets No.,of Hot Ribs KVA
AboveNo.of Lighting Fixtures Swimming Pool g ❑ in-
No. ❑ t3enerstors • KVA
No.of Emergency Lighting
No.of Receptacle Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No.of Gas Burners FIRE ALARMS No.of zones
No.of AU Coed. Tbtst No.of Detection and
No.of Ranges tons Initiating Devices
No.of Disposals No.of Heat Total Tota!
PurnpsTons KW No.of Sounding Devices
No.of Self Contained
' No.of Dishwashers Space/Area Heating fCYV Detection/Sounding Devices
m Healing Devices KW Local ❑ �'ConrieiCllon❑Other
No.of Dryers
No.of No.of Low Viol
No.of Water Heaters KW Signs Ballasts Wiring n G ''a '-L
r !�
No. Hydro Massage Tubs No.of Motors Tbtal HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES G NO O 1
have submitted valid proof of same to the Office.YES O NO O If you have checked YES. please Indicate the type of coverage by
checking the appropriate box.
INSURANCE O BOND. O OTHER' O (Please Specify) - (Expiration Oats)
Estimated Value of E Work S l d6
Work to Start o Inspection Date Requested: Rough – Final
Signed undor the Penaltes of penury: 1 9Q1G
FIRM NAME LIC. NO.
Licensee n nal d A Rrnnks Signature LIC. NO. . 1231C-
sus.
1231C_--Bus.Tel. No. _(2r03) 741-4008
Address 111 Morse Street. Norwood MA All.Tel.No. f 18 t> 7
9A-i t Ji
OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does___ not have the Inswunce coverage or Iia substantlal equivalent as re-
quired by Massachusetts General Laws. and thni my signature on this permit application waives this requirement. Owner Ment
(Please check one)
...Telephone No.. PERMIT FEE i.--al-0-01—
Mannsi—a of a..nnr ne Anont) I W.M115
Date. .
TOWN OF NORTH ANDOVER
° p PERMIT FOR PLUMBING
i •
♦ i !
�,SSACMUS�
Th';•'s certifies that . . A U q j
%M0C�V3"4t A
hasjpermission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . .H 4?L?l 1.. . . . . . . . . . . . . . . . . . .
at. . . . . . . . . . .-
. . �� . . . . . . . . ., North Andover, Mass.
�. . .
Fee. . . .33. .Lic. NoJ : .� 89. . . . . . .4-.;! 1.
PLUMBING INSPEC�i oR
Check J1 n �' O
5241
i V
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS �'
Date
Building Location 65 M , (( / AY AJ I.,, -+/ �� Permit#
Amount
Owner y A U G N T
New Renovation FRI Replacement ® Plans Submitted Yes No
FIXTURES
04 -let0-0 a
O
U
H > H z �" 0-4 w
3 *4 M Q a c7 A a ra
Stsas E
>�s>avEvr
BE)HIDCR
M HJOOR
3M HDM
4M>tiIfM
5M fum
6M HAOM
7MHDM
SIH HAOM
(Print or type) Check one: Certificate
Installing Company Name VCUQ G 1i ,� ❑ Corp.
R
Address S^ /bt c b►N^�e� N i9-�l Partner.
/►'t{ /lose—. Mg o �i ?
Business Te ep onej /_ G G Firm/Co.
Name of Licensed Plumber: tom sA J Y U41 cAl
Insurance Coverage: Indicate the type of insurance coverage by Checking the appropriate box:
Liabilijy insurance policy 19 Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three i*'urance
Signature
Owner � Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach efts _lu bi ode d Chapter 142 of the General Laws.
BY ignna u'f�eof Eicenseu riumDer
Type of Plumbing License
Title a
City/Town icense IN um er Master ® Journeyman
APPROVED(OFFICE USE ONLY
N° 1 7 9 6 Date..... �P�� � .l......
I NCRT1�
" TOWN OF NORTH ANDOVER
r0 ,,1-°-6..OO
PERMIT FOR WIRING
SS c US
This certifies that ...... m1. ....�:...(-ec. ('C,
u, has permission to perform ..... .jt!!t.. .R 4..l.....�, ,/�. `'
.. .... ..............................
SC� wu2
wiring in the building of
�!!� -7f........................
at..../ i ....... l ....... .... . .....................
,W,h Andover,Misse�
Fee.. .. . .... Lic.No' j........... � ... ....... .
GC 1R AL INSPECTOR
C (f (-7j 7�
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
Date. . .:'t.L. v Z. . . . .. . .
,,FORTH
pF . ,M
o? °." p TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�9SSAC MUSEt
R
This ceftifies that . tj. . . .C� `� .�' . . . . . . . . . . . . . . . . . .
has permission for gas installation . �zn f t?�
in the buildings of . .
at Z . . , North Andover, Mass.
Fee. ay. . . Lic. No.. �( �.
' GAS INSPECTOR
Check#
r
4ifL9
MASSACHUSETTS UNN ORM APPLICATON FORPERMIT TO DO GAS FITTING
(Type or print) Date �� / �/ a .2-
NORTH
-NORTH ANDOVER,MASSACHUSETTS
Building Locations �0 1 1"W t/ Al AJ JQ j. Permit#
Amount$ QO
Owner's Name ® tJ 9 T
New Renovation ® Replacement ® Plans Submitted ❑
10
.�
a o $ . :
SUB-BASEM ENT
BASEMENT
1ST. FLOOR
2ND'. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print pr type) 1� } one: Certificate Installing Company
Name Y a u $1,14 a A Corp.
Address -3 �. M a—✓1`a,'d AV � Partner.
I ,eiresc ✓A4 e IlG
Business Telephone_ ) p �e/, a _
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
i have a current liability Insurance policy or it's substantial equivalent. Yes ® No:o
If you have checked yam,.please indicate the type coverage by Acing the appropriate box.
Liability insurance:policy Other type of indemnity 0.Bond D
Owner 4s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.t e neral Laws,and that my signature on this permit application waives this requirement.
Check.one.
Signature of.Owner or Owner's Agent Owner Q Agent Q
I hereby certify that all of the.details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions ofthe.Massachuseus Stat C and Chapter-142 of the General Laws.
Signature of ticensed Plumber Or Gas Fitter
Title Q Plumber /,2 (1 2 -
City/Town Gas Fitter License um
0 Master
PROVED(OFFICE USE ONLY) 0 Journeyman
FORWARD
The Co rnmonweairn oj dM a ach setts "Ce Use Only
DepQTiCflt OJ Public SafetyrereDepartment
od
Occupancy b Fee
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90
heavee blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL 0 ON) Date l5C y
City or Town of /V 0 / To the Inspector o&ires:
The undersigned applies for a permit toperform the electrical rk described be w,
Location (Street & Number)
MAP
Owner or Tenant .T
Owner's Address
Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box)
v_T•-
P+ar;c;e cf 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 Aapacity
Location and Nature of Proposed Electrical Work C e T
>7 1
No. of Lighting Outlets No, of Hot Tubs No. of Transformers Total
KVA
No. of Lighting Fixtures Above In-
No. Swimming Pool grnd. ❑ grnd. ❑ Generators KVA
No. of Receptacle Outlets No. of Oil Burners No.
o fvEmergency Lighting
BatUnits
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
Total No. of Detection and
No. of Ranges No. of Air Cond. tons Initiating Devices
No. of DisposalsNo. of Heat Total Total No. of Sounding Pumns Tons KW g Devices
No. of Dishwashers Space/Area Heating KW No, of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local Municipal ❑Other
1:1Connection
No. of Water Heaters KW INo, of No. o Low Voltage
Sims Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
i
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
!� I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YESEL NO C] I have submitted valid proof of same to this office. YES® NO C]
If you have checked YES, please indicate the type of coverage—by chec g'lthe appropriate box.
INSURANCE 1 BOND C-] OTHER 17 (Please Specify)
n Da e
Estimated Value of Electrical Work $ Exp rati )!
Work to Start Inspection Date Requested: Rough Final
Signed under the enalties of perjury:
FIRM f1AiiE il C �A LIC:. NO. 3
Licensee 14. -7—aA- Signature LIC. N0. 59 3 3
Address 16 Z /f# us. el. No. JG� &
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S /S • �"
Signature of Owner or Agent
3770 Date..u�...........................
Y
NORT"
°ft�``°:• '"° TOWN OF NORTH ANDOVER
o p PERMIT FOR WIRING
• i r
•O+ten° ��'(y
ACMU`��
This certifies that ..................,:....���::'.,::.....:.._ ..........................
p has permission to perform '..............................................
wiring in the building of..............:. ...............:..................................................
at./'..6. ...........??2 � :.........:Q:.........-:............. .North Andover,Mass.
�7� ti
Fee..215—..IT....... Lic.No.............. .... . ... .......................
ELECTRICAL INSPECTOR
Check !i _L�
Official Use Only
Permit No. LS 7CJ,, r
a --a 4 PuR-s4ro 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 CMR/12:00
(Please Print in ink or type all information) Date �� 9
To the Inspector of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical workk described below.
Location(Street&Number
Owner or Tenant J)/',r Ct1!7__., ��
Owner's Address
Is this permit in conjunction with a building permit Yes W--f No ❑ (Check Appropriate Box)
Purpose of Building � Utility Authorization No.
Ebsting ServiceAmps Voits Overhead E— Undgmd ❑ No.of Meter_
New Service Amps volts Overhead ❑ Undgmd ❑ No.of Meters
Number of Feeders and Ampacity e r f
Location and Nature of Proposed Electrical W
i
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
Above ❑ In ❑
Ngo.of Lighting Fixtures Swimming Pool gmd ❑ grnd ❑ Generators KVANo.of Emergency Lighting
loo.of Receptacles Outlets No.of Oil Burners Battery Units
o.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. Pumps Tons KW No.of Sounding Devices
No./of Self Contained
No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices
❑ Municipal ❑ Other
No.of D rs Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Signs Bailases
Wiring
_
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
I�SURANCE COVERAGE—Pursuan to the r ui emen6 s of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO =
t — = the of coverage b checkin theappropriate box
�d valid roof of me to the Office YES— NO ft u have cher YE ase indicate typey g
h p same you � - A�
1 -
i iiVSiiiwivCE = iivNi, = OTHER,= (Please Specify)4 �� �..�!
(Expi.ztio.n.Date)
trmzte_ lal!..e l v'dorlc5
Work to Start Inspection Date Resquested Rough Final
Signed FIRM NAME rthe Wattles of perju LIC.No.�/�Cl
Li�ensee Signature f ke,i k 4 IC.NO.
Bus.Tel No.
Address /I iAft Tel.No.
OWNER'S IN U E WAIVER. am aware thaft the Licenses does not ave the insurance coverage or its substantial equivalent as required by Ma sachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMITTEE $ /4
(Signature of Owner or Agent)
tZ 6 5 2 Date.......
"ORT4
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
CIM4U
This certifies that ..A ...... ............................
..........
has permission to perform ............ ........
wiring in the building of........... ..................................................
ON
at....... ....... North Andover Mas
es
Fee...J..0.!A(�. Lic.Nod..Q� . .. ...... . .....
R
ELEcrRICAL INSP]9'�A . ......
Check #
_ _ C o,nmonwea(Ui o/Madeacliuielb Official Use Only
- _-CJeParfm.enf a��}ire �eevicee Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
(Rev.
11/911 (leave blank) j
APPLiCATiO�N FORPERMITPecordance W1111 tile aS
ERMIT TO PERFORM ELECTRICAL WORK
AH work to setts Electrical Code(NIEC), 527 CNIR 12.00
(PLEASE PRINT IN INK OR TYPE.,I LL INFORM,I T ION) Date:
City or 'Fotivil of: o ��}, Ot r.r�at.,t. To the Inspector of Jk'ires:
By this application the undersigned
Location (Street & Number)_ gives nonce of his or her intention to perform the elecnicai work described below,
Owner or Te nant 1JG � -,,
, , /1 &��C 0
����,,gyp
e�, , 7-_ Telephone No.
Owner's Address
Is this permit in conjunction with a building permit" Yes /- No ❑ (Check Appropriate Box)
Purpose of Building_,owe t<� �r`i U(ili(y Authorization No.-O-O 13
0C, r\n;ps/ / i f�C/Volts Overhead Cr- Undgrd
SCFN,1cC
U No. ui;�Ictcrs�
New Service � Amps ` �/ yQVulls Overhead � Undgrd ❑ No. ofiNleters.
Number of Feeders and Ampacite
Location and Nature of Proposed Electrical Work:
r �
1
Completion ort- olluwinQ ruble mov be uaivcd by the his tor orIVires.
No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total
Transformers
No. of Lighting Outlets No. of 11u1 Tubs Generators KN"A
No. of Lighting FixturesSwimnriug Pool Above ElAb ❑ o. o mergence rg rang
b grid. arnd. Batte Y Units
No. of Receptacle Outlets No.of Oil Burners FIRE ALAMMS No. of Zones
No.of Switches No. of Gas Burners No. of Detection and
Initiating Devices
A
No. of Ranges TonsTotaNo. of Alerting Devices
No. of Air Cond.
No. of Waste Disposers Heat Pum Number Tons KW No. of Self-Contained
p I........ - --
Totals: Detectioa/Alerting Devices
No. of DisInvashers Space/Area Heating KW Local ❑ Municipal
Connection Other r
No. of Dreers Heating Appliances KW Security Systems:
No. of*Nater No. of No. of No of Devices or E uivalent j
M%V Data ��rrino:
Heaters Suns Ballasts IN`o.of
No. Hydromassage BathtubsVo. of Motors Total HP Telecommunications Wiring: —I
No.of Devices or E uivient
OTHER:
Attach additional detail ifdesired, or as required bi,the Inspector of Wires. '
INSURAINCE 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 issuin; office.
CHECK ONE: INSURANCE tj BOND ❑ OTiIER ❑ (Specify:)
Estimated Value of Electrical Work: - ;U (When required by municipal police.) (Expiration Date)
Work to Start: - _� Inspections to be requested ill accordance with MEC Rule 10, and upon completion.
I certif}', under the/mitts and penalties of petjur)•, rhat the infortrtatiort oft this application is trite and complete,,.
FIRM INA f'IE: t
LIC. NO.: ,3&s,
Licensee: Signature LIC. NO.:
(If applicable, enter "ara rpt"in rhe/leen e number line.) Bus.Tel. No.: P3l�mZ^ o7U J
Address: �/� r u /tom('. /P/at lc.2 n 14 Alt.Tel. /-
OWNER'S INSURANCE iAIVER:I am aware that the Licensee does not have the Iiability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ o��;ner's anent.
Owner/Agent
Signature "Telephone No. PERMIT TLE: S
FP""I - T_k -1�4 P ."I f!�_��:T I,-"I Fl(�f J( P 7j(-
A L -I
I AcoapCERTIFICATE OF LIABILITY INSURANCE
3ATE IW4,C
pHAS-1 i 011
THIS CERTIFICATE IS 7S_$UED AS A MATTER OFINFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
mF&T Insurance HOLDER THIS CEPT(r(CATE DOES NOT AMEND, _!-)(TFND DR
1.75 Derby 9t. unit 40 ALT FR_THi COVERAGE AFFORDED SY THE POLICIES BELOW_
Hingham MA 02043 !NSURER-S nHFC)QDING COVERAOR
Phone. -781-740-6300
Travelers InAurance
I 95LA9,
A-Phase EIaCtriC, LLC INS.UREI 0
1141'st'o wryNNRoti
o 13 55
COVERAGES
THE POLICIES CF INSURANGF LI$YED 89LOW-AvE LEEN ISSUED`O +E IIGUrr.L)NAKED
ANY RrOUIrt,-MEWT.TFW OR CONDITION OF ANY CorjYPACT OR OTHER DCCLJ1XQ1 VOrH RFRPCC!`0 VHICH I-'L5 CERn. 0(.AT!!MA• nr t"tUrD OR
;e
MA.YP=ATA IN.THE IN FURAN CE AFF ORO CC))v THE POI.C.I E6 r)ESCP ISE D H..RN E1,1��)L JE C_ OALL'"H[t ItRPE E>',CLUBIOI4,q :I"D;_trVj'SC"S1
DOLIFLES AGGREGATE LIMITS SHCIAN LAAY KAvE BEEN PlEXICED EY PAID C: ms
LIMITS
LTR T-(PE OF INSURANCE POLCY'NUN BEP DATE(NW"D0,YY
LGP—L LIA&LITY EACH. 000,000
A SX.1 COMMEPCIAL GENERAL LIABILI—, 168 0 6 3 5DO f;68 COV)1 08/21/01 08121102 FIPIE DAMAGE!Al. flel $ 300,000
CLAIMS WOE 0 EXP(A 000
°r-SONAL a ADV NJIII" S 000 00�cl
s 2 000 0)Q
r7,tt,L AGGREG.A.71!LIME'AFFLdS PER. Q n I r.T n LA P 71 P c: 3 2,00c,000
,ICT
AUTOSA081LE ILLAMLITY CDbARINEC-i11w,LF L"I' 15
i!E6 1,000,000
A AM'ALTO 08/21/01 OR/21/02
ALL OVM ED i UT 0S BOD L"iI,IJI'p,
P.,
X HAFbAulos
LX NON CVINED AUY0A
—---------
Z;ARAGE LIAMUT" -UT,-I 1:)N;. CA A,,CI Dt N I I
ANY ALr-o I �-T,4PP TI-JAN -iA&CC_j
OW,
XCESS LIABILITY
OCCUR LA nab MADE
3_.-.-_.-_.__.
OCOUCTIDLE
RET.ELATION S
VVIORXERS C064PENSATIC.Q AND x 'rOPY_IkATS____j EP
EMPLOYERS'L IA BIIJTY 100,000
IUB 15 97 A 5 4.P, 10%16/011 10/16/02 AOCIDENT
4L OiSGA&F EARI`JrL0yE
LL I-N 3 EASE I'(,L I 1,:'1.1W! V500,000
CeSCRWTION Or iV00k.riAVNTIPPLCIAL PROVISJONA
Per their contractual agreement with the- named insured, McBride
Cm Additional insurod; but only with YQgpQct to nf the named
insurad on their behalf.
CERTIFICATE HOLDER N AoL)mONAL INSURED IM9ILjRER LE-I"TER: CANCELLATION
I 9NOULD AN,OP THE ABOVE oF,,,cRIHF0 F,,)L(;ie5 HE CANCELLED APPoRr THF"X)1RArX.)N
DATE THEREOF,VHE ISSUING In.SURER WILL U11]i=A100 Tn-AIL .30—DAYS'tri-�TtP
10Y]CC TO THF CERTIFICATE ')FP WAMPr)70'HF L FET,50T FAILURE 70 00 SO SMALL
imPDSF MCI OnLIC.ATK_0"',IA-1 I OF AN'(0 L)"4 7',f IIN�URCR.1-4 ACE-17C OF
—4U T_
:HOP EOR RES NTAT1Vv.
-----------
ACORD 25S(7/97) C1
ACORD
CORPORATION 1988