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HomeMy WebLinkAboutMiscellaneous - 172 OLD FARM ROAD 4/30/2018 (2)A It Date ........ - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ has permission to perform ........ 5n< :'.:77-/ ... ............ wiring in the building of ........... 7v�- /? ..................................................... at ........U. Z.. ..... ..... ,.North Andover, Mass. Fee -42", Lic. No. ................ Check j 7 UE*CI-M* ELECTRICAL*'* **'* 8753 W Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. J 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 PRINGncle K OR TYPE AL INFORMATION) Date: 5))))D City oof: To the Inspector of Wires: By this applicatio rsigne gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /p► t:{iV1r1 Owner or Tenant K)n -)(x,(,jr r`jlir Telephone No T , Owner's Address I I 1 j Is this permit in conjunction with a building permit? Yes ❑ No x BLDG PERMIT # Purpose of Building Existing Service _ New Service Utility Authorization No. Amps / Volts Overhead ❑ Undgrd ❑ Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install low voltage security system at above location Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pum Number Tons KW No. of Sett -Contained No. of Waste Disposers p Total Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Other Local ❑ of Dryers Heating Appliances KW kru—ritNo. yy No. of De em . or Equivalent 1 No. of Water KW No. of No. of ; Nooeve Heaters Signs Ballasts uivalent No. Hydromassage Bathtubs No. of Motors Total HP Tel No of Devicesons or EquivWirinalent OTHER: 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: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no pen -nit for the perfonnance 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 andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Brinks Home Security LIC. NO.: Licensee: John Holmes Signature ��� �. LIC. NO.: 749C (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-657-0443 Address: 155 West Street, Suite 6 Wilmington, MA 01887 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License LIC. NO.: SSCO 001163 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not hca e the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ® owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ `J� -77 t i Location / -)--�'�' No. "n Date TOWN OF NORTH AN -DOVER s Certificate of Occupancy $ Building/Frame Permit Fee $ � i Check # A3 555. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 Building Inspect Date ....�.C.>7 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............. ....... I....... ' .. . 4 has permission for gas installation ... . .......... in the buildings of . . . . . . .................. at . � V,� . . :(�� f'-. Andover, Mass. Few Lic. No........... . ........... OAS INS .. Check 4116 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date -0c19 Permit Building Location K-�,,4r+f lba Owner's Name -S et V(420 S J. Type of Occupancy New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑,r " Installing Company Name AMERIgas PROPANE CO INC Check one: Certificate Address 215 Boston Street ® Corporation Tonsfield Ma 01983 ❑. Partnership Business Telephone 978-887-2353 ❑ Firm/Co. Name of I ieenseef Prumher nr Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. 1 Yes 1CJ No U If you have. checked yes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy X3 Other type of indemnity ❑ a�Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance cover`ge required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the General laws. ey. Tie of License: Plumber S+gnature of Licensed Plumber or Gas Fitter Title Gasfitter Master License Number City/Town Journeyman I USE ONLY1 SEINE! MINNE NEI �i���■111111■�����vv���v�� MUM ■111111111111111111111 111 Installing Company Name AMERIgas PROPANE CO INC Check one: Certificate Address 215 Boston Street ® Corporation Tonsfield Ma 01983 ❑. Partnership Business Telephone 978-887-2353 ❑ Firm/Co. Name of I ieenseef Prumher nr Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. 1 Yes 1CJ No U If you have. checked yes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy X3 Other type of indemnity ❑ a�Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance cover`ge required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the General laws. ey. Tie of License: Plumber S+gnature of Licensed Plumber or Gas Fitter Title Gasfitter Master License Number City/Town Journeyman I USE ONLY1 Date .�.-. .) - ....- ( I- .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 77 This certifies that.. 1/. '� .... /.'X* r............ has permission for gas installation ............ in the buildings of ............................ atr-Olm.<y ... North Andover, Mass. Fee.. Lic. No......... 9AS INSPECTOR Check # 4124 MASSACHUSETTS UNWORM APPLICATON FOR PERNUr TO DO GAS G (Type or print) Date 0 . NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New Renovation 0 Replacement El rr . Permit # Amount $ Z Plans Submitted 0 one-• Certificate Installing Company Corp_ Address Partner. Business Telephone r -• r r .r Plumber or r- �. INS URANCE COVERAGE Check one: I haves current liability Insurance policy car it's substantiae equivale. aL Yes No D if you have checked M please mill the type coverage iry checking the appropriate box Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver. I am aware that the licensee does nothave the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this.permit application waives this requirement: Check one: Signature of 11:=_or Owner's Agent Owner 0 Agent El i hereby certify that all of the details and inknnation 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 ed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts S e Code ar 6C)ap jVZ o C�rleral Laws. City/Town (OFFICE USE ONLY) S' lure of Licensed Plumber Or Gas Fitter Plumber a Gas Fitter r7cense Numoer 0--m-aster aster 0 Journeyman • t ww�ww�wwww�wwwww�w�wwwww�ww� `, ©�wwwwwwwwwwwwwiwwwwwww�w , , ' wwwwwwww�wwswwwwwwiwwwww�w . , , , ' wwwwwwwiwwwwwwwwwwww�www iwwwwwwwwwwwwwwwwwww�wwwa ' , ' w�wwiwwiww�w■®wwwwww�wwwww�ww ' , , • ww�wwwwwiwww�www�wwwwwwwww�w , www�w■w��w�wwwwiwwwwwwwwwwww� , wwwwwwwwwwwwwwwwwwwww one-• Certificate Installing Company Corp_ Address Partner. Business Telephone r -• r r .r Plumber or r- �. INS URANCE COVERAGE Check one: I haves current liability Insurance policy car it's substantiae equivale. aL Yes No D if you have checked M please mill the type coverage iry checking the appropriate box Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver. I am aware that the licensee does nothave the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this.permit application waives this requirement: Check one: Signature of 11:=_or Owner's Agent Owner 0 Agent El i hereby certify that all of the details and inknnation 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 ed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusetts S e Code ar 6C)ap jVZ o C�rleral Laws. City/Town (OFFICE USE ONLY) S' lure of Licensed Plumber Or Gas Fitter Plumber a Gas Fitter r7cense Numoer 0--m-aster aster 0 Journeyman " TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: �� DATE ISSUED: SIGNATURE: Building Cominissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 179 01A 540M )fid • � a Map Number Parcel Number 1.3 Zoning Information: 11.4^ Property Dimensions: Zonin District Pr sed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Simply M.G.L.C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ft✓ On Site Disposal System 0 Public B/ Private ❑ SECTION 2 - PROPERTY OWNERSEU/AUTHORIZED AGENT 2.1 Owner of Record —� AQdZOS >�� ��� 1--,/4-PAA, ) 1. Name (P ) Address for Service: §ignature Telephone S/�)r✓L C _ 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ /�1CDE 2 o cls A PAr 1/412?.0 Licensed Construction Supervisor: b� a License Number 7% j3 i 4 i1 Y [�.�Ci� � /•i-� f �; �}N[� Addr Expi tion to Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ /•Z �3T / Company Name Registration Number /� t f ,%� � � AAA 71 13 121 . h T [ A). �D j /i V r— r/T+'V te�%t A ` Exptra ton ate Addre /'� lid' % Snature a,Telephone t �a SECTION 4 - WORKERS COMPENSATION (MG.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 buildog permit. Signed affidavit Attached Yes ....... V No ....... ❑ SECTION 5 Description of Proposed Work (check all anolicable ) New Construction rPr�, Existing Building ❑ Repair(s) ❑ Aherations(s) ❑ Addition Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: PLG572 (:I mss» r t A)9J [,V U ti & J-,,�AIC t eo d F Cr�!!T �e 2v eA-2P4.AvrC.c Q 44 F,Qe I SF.CTTON 6 - F.STTMATF.D CONSTRTTCT ON COOTS I Item Estimated Cost (Dollar) to be Completed by permit applicant I�. tSLf3' 1. Building 0 p (a) Building Permit Fee Multiplier 2 Electrical moo, 00 (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection A 6 Total 1+2+3+4+5 Check Number a�,�:iiVry /a VWPI,L1CAu1tlVttIGA11V1V lvR� C;VMYLElEl) WliN;1V OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, I r TA 4 f' %C'/� as Owner/Authorized Agent of subject property Hereby authorize ���1' pip Zi P A- I Ve to act on My beha/l��, in all matte rssLLel ttive to work authorized by this building permit applicatio lyl��, rr1 i /J� Si ature of(�- r Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 6yb<-�/1!!e-Y`i✓►..�4 r' 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 Owner/ Date NO. OF STORIES SIZE BASEMENT OR SLAB ►� SIZE OF FLOOR TMBERS I 2 ND 3 SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DRAENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION********************;** n APPLICANT LOCATION: Assessor's Map Number SUBDIVISION STREET`�,Cc RECO MENDATIONS OF CONSERVATION ADMINISTF COMME NTSI �. t�,, TOWN PLANNER COMMENTS s FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS )R DATE APPROV513 _ DATE REJECTED i DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED It PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm PHONE PARCEL 6, LOT (S) ST. NUMBER USE DATE i; l Ll C, J J C. (55 �' v ] ems' L+. y Cj �-� U i1J C)c'T liJ F^ �1 � S cr QJ Cn IL-1 w r U `` ~ Lij r lij Q7 L i wrti IiCI. 17. =� Qs 0 LU � 17" LLJ rti r. Q U wa�Ch 1�4 CL Cr - U ) ;z t,- rJ l,J C) IJi TT - r �>ctC, n�J t x W r a_ I r• N� { U 00 �0171 3 Ir '-.l_t'd ?Z2T',=F,^L 19 DNI'333HI`_:)N3 0,3'=; �-,a:'?o 3nl z- f. — e% —r-anr i I991YA1go]=►Is) :1I:I_101IIpJ-vI`a:� Certificate of Occupancy $ Building/Frame Permit Fee $ - L* Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # . % iii atgp iv 1 .fF, ,h- .0i,F m (A, Mi ' C-1 c j i tr)r� V A1C.: r ,7C'7'1Zt Lrl .y 1't - J` i ^ / "J -7/' J -c , 0 V, G/c C3 `J � hM1 r• � l rJ � E •� 7 _i _ (��i 1' `'- is � ,-�`'`� �.' a �' "- 4.t :> � G �') "'`•� C3 .1c Cl.Li v7 FSa, Eli CLI iv Ll tti' v ot ,h- .0i,F C'7 C31, U"1 r•. C6 rt" q m (A, Mi ' C-1 c j i tr)r� V A1C.: r ,7C'7'1Zt Lrl .y 1't - J` i ^ / "J -7/' J -c , 0 V, G/c C'7 C31, U"1 r•. C6 rt" q e m (A, Mi ' C-1 c j i 1 r ,7C'7'1Zt Lrl .y 1't - J` i ^ / "J -7/' J -c , e r ,7C'7'1Zt Lrl .y 1't - J` i ^ / "J -7/' J -c , 0 V, G/c N, S fiT_ J \ L-�j Cl.� LZ C)w v 11103 03 0 126ryL T'.^A. 0hJ I':13at4I °?t•a3 9Ci 3111 F� :!.7� i z:F.:_:� j 0`4I;�j33NI''-1h43 .J3 -' 9a:911 3i"IJ 2E. -6Z. -i4 f C`•� � rte) 4. G� Fr c� �J �T. Y J ( <[ cz it M1 z Q ii C)s �1 rti J x� tej 4 r~ d F� :!.7� i z:F.:_:� j 0`4I;�j33NI''-1h43 .J3 -' 9a:911 3i"IJ 2E. -6Z. -i4 f f BOARD OF BUILDING REGULATIONS 3 L•id6nse: CONSTRUCTION SUPERVISOR 'Numb-" CS 063173 131 _rthdate�U1/2171068 expires: `01/2172004 Tr. no: 17339 j FREDERICK A PAQPAlARDO. } 71 BRIGHTWOOD AVE J` o y N ANDOVER, MA .01.845:tc %� Administrator E f� Board of Building Regulations afid Stantl trds y ;AcIIE I�IAPROT E ONT RA TOWRIT RM trrgtioin 1:''34J E7( �dtlon ..: ryp DSA t I P..I',..^. �JI�JERS &DESIGNgI.O;° F:RtDRIC PAPPALAR�� r _ t ^^AND VAR INA 01$45„ . �►il%t�Piss ra'tor, �I Y, U am a homeowner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit all work myself. Print W3 TAW r E!31 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Insurance Co. .(._.# cempany name: Address G(ty:.. Phone.* Failuf* to secutO coverage as squired under Section 25A or MGI 152 can tape to ft Womition d aiminai penalties, d a fine up to $1,500.00 and/or one years' umprisonm t as'wetl as ciW penalties in the form d a STOP WORK C�ibl�`t and arm of ($100 oo) a day against me. i understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for coverage verNication. I do herby cerfify un the pains and pens of perf ury M& the k*nnatiw provided above is brie ani/correct Signature 7 Date_q/ Print name �IZi�J Ka ��1- r"1'� (s/ 2 � Phone#`4'�la-39S, Official use only do not write in this area to be completed by city or town officiar I]Oireck if immediate response is required Building Dept Contact person: Phone �ZM WORKAMY S CoAlPENSAT10;? U Building Dept p Licensing Board p Selectman's Dffl-ce Q Health Department 0 Other A North Andover Building Department Tel: 978-688_954 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be . disposed of in a properly licensed solid. waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: CK (Location of Facility) Signature of Permit Applicant i Date NOTE: Demolition permit from tije Town of North Andover must be obtained for this project through the Office of the Building Inspector N � V r4 11-1-J\-) m m C m Cl) 0 m _) H .0 C � O � CA Cl) 10 0 co C0 Z y E O -o CL ? O d �• CO) ''O O � O 8 m �� 0 Q .� c a CD CCD O CD mm C CD Nf CL to O y O I CO CD ca 10 c?�O m 2 O —• ca cr N y C7 C n m Z ai O 5 .dr m N ?5 T CLm O C H C y —•1 o f m m; o n O Z�•� 1 Om N O 7R: co O �. a H •S.j% r CL. Cm V/�J ) m .m N V�_ 7 C7 fl r^' \ J N ' _ `• O N tom} O t Q' ►may (� � � � C. CL c CA ` •ca N CD H CD O O0 �Z O z CD 3 �.o Z p=� V46.CD o�. Q� c � ^'� � H co o C ►o : -� " Y o = c� cn cn z O co ►� f.y ° ; �' t" "ti /rH a' a 0• CJ v N x R x y 0 0 c 39C1 /- -1.1141- Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform ... ............................................ wiring in the building of ........... ...................... *' W .............................................. ........... at......1 -� ......... ........... ...... -, North Andover, Mass. ............ 4 ....... ........ Fee...... .......... Lic. No . ...... ...................................................... ELECTRICAL INSPECTOR Check # at.�iwrt+xurt od ,au6lle Satiety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official Use Only ,Permit No. -� ?4 Occupancy & Fee Checked 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) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number_ ,, � � 2 t l / .l' 1 r WL l _ I �` Owner or Tenant U- (,\ ` - Vim%AI - Is Owner's 211 Date To the Inspector of Wires: Is this permit in conjunction with a building permit Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Vats Overhead ❑ Undgmd ❑ No. of Meters New Service Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Overhead ❑ Undgmd ❑ No. of Meters OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws 1 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 you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND = OTHER = (Please Specify) 0 (Expiration Date) Estimated Value of Electrical Work$ , 100 Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: r `—� FIRM NAME E L A � s < 0-(,,,.2,J LIC. NO. 35099- �,4 U�nn < 1 d NO. 3,5-O9-4- E - Bois. Tel No. Address 'Aft Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the 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) No. PERMITTEE $ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Rece tacles Outlets No. of Oil Bumers BatteryUnits No. of Switch Outlets No of Gas Burners i FIRE ALARMS No. of Zone No. of Detection and Total No. of Rang& No of Air Cond Tons Initiating Devices Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers S ce/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers 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: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws 1 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 you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND = OTHER = (Please Specify) 0 (Expiration Date) Estimated Value of Electrical Work$ , 100 Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: r `—� FIRM NAME E L A � s < 0-(,,,.2,J LIC. NO. 35099- �,4 U�nn < 1 d NO. 3,5-O9-4- E - Bois. Tel No. Address 'Aft Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the 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) No. PERMITTEE $ (Signature of Owner or Agent)