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HomeMy WebLinkAboutMiscellaneous - 198 DALE STREET 4/30/2018 (3) 198 Dale Street II IIS BUILDING FILE Date.. .� I Z T Of -1 of TOWN OF NORTH ANDOVER 4L PERMIT FOR GAS INSTALLATION SA US -r This certifies that . . . . . . . . . . has permission for gas installation . . . . . . . . . in the buildings of . Af'." �!-.f.1..4; ... . . . . . . . . . . . . . . . . . . . . . . at . . . ", . . . . . . . . . .I North Andover, Mass. Fee. Lic. No.. . . . . . . ASINSPECTOR Check# 7 t7" 6439 MASSACHUSETTS UNIFORM APF-i'=,►TION FOR PERMIT TO DO GASFITTING x .. (Print or Type) _ Mass. Date uYV - 20 08' Permit# �y 3 Building Location -TA Owner's Name �S Telephone -4 � Type of Occupancy New Renovation o Replacement Plans Submitted: Yes El No❑ m N R F m 4' d d i +, V m C I: = 0 an d = Q Q W d W O > d 12 0 O > '� a+ V aN+ d C O C ` O N t W = O = u'.. od - v W mo oI— O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR ` 3RD FLOOR f 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name EnergyUSA Propane,Inc. Check one: Certificate Address 100 Myles Standish Blvd.,Suite 101 XX Corporation 132 C Taunton,MA 02780 Partnership Business Telephone (800)822-1300 X8055 Mike Smith Cell(508)922-7891 Firm/Co. Name of Licensed Plumber or Gasfitter William Kent Corson(800)822-1300 X8051 Cell(508)294-6660 INSURANCE COVERAGE: EnergyUSA Propane,Inc. has a current liability insurance policy or its substantial equivalent,which meets the requirements of MGL Ch.142. Yes X❑ No If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy X❑ 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 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 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Code and Chapter 142 of the General Laws. t, Type of License: By FlPiumber Title X❑Gasfitter Signature of Licensed Plumber or Gasfitter City/Town X❑Master APPROVED(OFFICE USE ONLY) nJourneyman License Number 3707 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE 20 GASINSPECTOR Date �. TOWN OF NORTH ANDOVER PERMIT FOR WIRING gB�cHus� This certifies that ... �'.P-QJL �(„G� ..... .................... .............................................. has permission to perform ..hr -P, ... wiring in the building of.............. 1 ��� '-st AJ ................................................................................... at '....�.... .......t.:!C�� .......,,..__..�.,,..``.............:T......................... orth Andover,Mass. A 0V Fee : ............Lic.No�``g4.0;; ... �!............... . EL CTRICAL INS ECCOR Check# ,��� 4c, bp-- y . Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ����►� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of hisor her intention to perform the electrical work described below. �; � ��4// Location(Street&Number) / P S T Owner or Tenant ®A►-i TA K e S 1 il P,' Telephone No.57 P T96 —e 731� Owner's Address 57,49-kvi 4 Is this permit in conjunction with a building permit? Yes ❑ No Q"-- (Check Appropriate Box) Purpose of Building S/Z-y � '(mac rut• (V 1 GJe ll 1 hey Utility Authorization No. - Existing Service 6 O Amps 42 d O 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: j,U S JW/l Completion of the following table may be waived by the Inspector of Wires. yZ f � No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.oTotal KVA No.of Luminaire Outlets No.of Hot Tubs Generators C KVA /,k-tl No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting rnd. grnd. Battery Units r� No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and 3 Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices " ' No.of Waste Dis posers 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 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: _ Attach additional detail if desired,or as required by the Inspector of WYres. Estimated Value of Electrical Work: SU 6 (When required by municipal policy.) Work to Start://— /�/ /3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. M 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:) Sig fle4-y 3 03 �} f3pn A b.Dv S4-3 3 �-- Icertify,cinder thepains andpenalties ofper ur tli a in ornmtion on this application is true and complete, FIRM NAME: ,.� jLf/2 it�G t ��✓� LL I LIC.NO.: A y yad CS Licensee: &12p>Zi t/c /L 5ka f f t1 Signature LIC.NO.:,2 VVd of Gr (If applicable,enter " er tF in the license number line.) Bus.Tel.No.•,57Y-G�3 SYoZ/ Address: ��y '`//✓7 �'ry'Od al G"� !�t►�t'X111W 016 Alt.Tel.No.• 12!'3-2522Q(� y *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/Agent PERMIT FEE. $ Signature Telephon No. . tae-� �1 t � ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the r 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.G.L c. 166,§32,an r Y 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 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: ° Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comm ts: Inspectors ignature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com s 1 The Commonwealth of Massachusetts 57 Department of Industrigl Accidents Office of Investigations IV 600 Washington Street Boston,MA 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Lely `` Name (Business/Organization/Individual): S Ar r cJ e.4��`1 Address: o�SyU City/State/Zip: I" V-e,,J m Phone#: � 7G ' l V3S �oZl Are yqu 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. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 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 1211 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. f Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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:j" Job Site Address. 1r a S T 2<Citi "r /L L el City/State/Zip: AJd°�j Q 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. Ido hereby cert r thepains andpenaltie fperjury 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#: f Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Commonwealth of Mossachuseutts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel,#617-727-4900 ext 406 or 1-877,MASSAFB Revised 5-26-05 Fax#617-727-7749 wwwanass,gov/dia r i COMMONWEALTH OF MASSACHUSE S � BOAF� L�CT'R I C1 ANS ISSUES THE FOLLOWIIJ LITENS } AS A REGOURNEYMAN._ELECTR;I C I A FRfpCRICK R SKAFF f T rZ 29 ROLLING `'MEADOWS HAUfRHIL'L MA 01832-8815 `.:. 24402 07/31/.x6 39174 s GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: I A St A ►� GENERATOR kw 17 /-c w NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: S/C-A ff off PHONE NUMBER: 9-2V 37S _ oVyy ELECTRICALGAS :) ESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: 9 f=T r/vM *ZONING DISTRICT. — *PLANNING APPROVAL (IF IN WATERSHED) // g 3 D l *CONSERVATION APPROVAL 11 t 13r�, IIt "AJo A,-pA-o-4-tp4A.'"` t;. NNNNNN�rth Andover MIMAP November 8, 2013 of s 11152 , r s _ ♦ •, t � y If a " n � t f a . yr K 9 , Interstates Interstate Major Roads Hodzontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack pORTN Valley Planning Commission(MVPC)using data provided by the Town of r EasementsOf „ go North Andover.Additional data provided by the Executive Office of 0 MVPC Boundary ? 't r6.s�O Environmental Affairs/MassGIS.The information depicted on this map is {Parcels 3 L for planning purposes only.It may not be adequate for legal boundary F -^- o definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING { } THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT # �o� w rwr �� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION SA us 1”=157 ft •�° t North Andover MIMAP November 8, 2013 I 037:B-0002_•'. -. _ ••:: ' '.•_ . � 06.4.0-00 0 037: 0072 7.,B--0073,' #240 #10 #34/ _ 064:0-001 064.0- 028 --- ie ore' 23lenore Circle ' :064.0-00 #228 #31 / 0000-0076 --.. •-� •--••••. .�/'%��- �..t :•--:..:_-'..�r-:-..-_ --:.. f...:.r:'::.:•_•• #220 ::. . :? .... n.!/ ::: a `:'• . .• :.: 37A200037' 064.0-0062 037:B-0001_:. :.•. :.,I;• -: :.` ° :..`. .j ;_ •. item rrotection / �e _ . ...�:: :..••:.. .• �� �7:B=000 / � 00Q, ;r.. .: ._• .•.::... �. .• 037.B-0005 03a.B-0007 ��8/�/ 064.0-0021 #11 #19.0 y-5tse�, a . N037:B-1142 # 8 #201 037:B-0 24 37.,B-0 j 06.4.0-01 4 031�' / #185 #153 037,B-- 037.B-0021 037.B-0022 / #yp 037.B-0064 #205 #95 037.B-0027 37.B-0034 037.B-0033 #100 037.B-0025 0375-0032 037.B-0026 —Rail Line '-«Wetlands Zoning Interstates Exempt Lands Busine s 1 District Interstate O Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —Major Roads 0 Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack IN Busine s 4 District NQRT1y Valley Planning Commission(MVPC)using data provided by the Town of Roads N Gene Business District Of t�ac 'ah, North Andover.Additional data provided by the Executive Office of IO t r• O r Easements Planne Commercial Dev 4e �s O Environmental Affairs/MassG15.The information depicted on this map is Corrido Development Dist 3 L for planning purposes only.It may not be adequate for legal boundary 0 MVPC Boundary O Corrido Development Dist O .-- definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER ❑Municipal Boundary G Corrid Development Dist �' 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Ind ustri I 1 District Zoning Oveday • - ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Indusin 12 Disinct 0 Adult Entertainment • i ,^, .1� OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT 0 Downtown Overlay District Illstriri 13 District S District * o .. •� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 93 ♦4 0 IndustHistoric District o+.r�o� j THIS INFORMATION Reside ce 1 District THIS Z Water Protection .Reside ce 2 District 7S O Parcels 0 R—ide ce 3 District SACN115� Hydrographic Features de ce 4 District 157 ft de Streams 1"= ce5 District aria ce 6 District ���age esidential District f Date....... '..`................. �aOR7M TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ��SS�cHusE� This certifies that `� � �/ ��rT` loQ ....w�. ..... ................ . ......... ��... has permission to perform .......... ............................... wiring in the building of n k „s,/!�..................................... e° at........................... ..........................North Andover,Mass. Fee.3.5-......ov........ Lic.No.f!Ut�74............A..� ...... LECMICAL INSPECM]f Check # 8323 X Commonwealth of Massachusetts Official Use Only Permit No. 93 Z..5 Department of Fire Services Occupancy and Fee Checked r` 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: 8/28/08 City or Town of: North Andover 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) 198 Dale Street Owner or Tenant Daniel&Joan Takasian Telephone No. 978-688-1354 Owner's Address Same Is this permit in conjunction with a building permit? Yes X No ❑ (Check Appropriate Box) Purpose of Building Single Dwelling 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: Wire finished basement area Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires 19 No.of Ceil: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 E rnd. rnd. Battery Units 4 No.of Receptacle Outlets 10 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 4 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: "'"'""""'".......... '" " ' """"' Detection/AlertingDevices 2 No.of Dishwashers Space/Area Heating KW Local Municipal El [:1 Other Connection pp No.of Dryers HeatingAppliances Kms' Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: I Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 1 No.of Devices or Equivalent OTHER: / Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 2860.00 (When required by municipal policy.) �* Work to Start: 8/29/08 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 X BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Sweeney Electrical Company LIC.NO.: 14917A Licensee: Darrell Sweeney Sr. Signature LIC.NO.: 35662E (If applicable, enter "exempt"in the license number line.) ! C11 Bus.Tel.NO. 978-939-5440 Address: 613 South Road Templeton,Ma 01468 Alt.Tel.No.: 978-257-7310 *Security System Contractor License required for this work;if applicable,enter the license number here: 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/Agent PERMIT FEE: $35.00 Signature Telephone No.