HomeMy WebLinkAboutMiscellaneous - 21 MORRIS STREET 4/30/2018CIO ODMPWQ�m N Date.....:...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........................... has permission to perform ....................................... wiring in the building of ....'.",/ ................................................. .h r at ..11........ls'?-a- .................................. .North Andover, Mass. Fee.... . .... Lic. No. .?.0 .. .................................................. ELECTRICAL INSPECTOR Z " Check # wU�_ 7717 rw, �� __dull+— •, Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. X717 Occupancy and Fee Checked tev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: %Df // d 7 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) c-! M DP- �t' S % �l.C—l; 7 �17�1 �/l1Q"A MI -9 d/ �s /IN Owner or Tenant A 1 y ��/Q�j'(� ,� Telephone No. 7F6 f Owner's Address 6{2 / S cS1�E6% /llr?OW AIVAd ' Is this permit in conjunction with a building permit? Yes No _ � ❑ (Check Appropriate Boz) Purpose of Building Ivy s�i//�%� �AS�/`t�UT Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: NIaDUEL LT -S -+- L- 6 -,}-TS /fS No. of Meters No. of Meters Atrach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete: FIRM NAME: WI LL /q Iq A/CWA4A/�l LIC. NO.: Licensee: jjy/(,L/AA4 l(/EWHqlV Signature LIC. NO.: (If applicable, enter "exempt " in the license number line) Bus. Tel. No.: Address: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L lc. 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 oneZ owner ❑ owner's agent. Owner/Age Signature Telephone No. �TF PERMIT FEE: $ «�. U McJuttuwtn ranee may De waived bv 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 SwimmingPool Above In ❑ Emergency Lighting nd. r Units No. of Receptacle Outlets No. of Oil Burners ALARMS No. of Zones No. of Switches No. of Gas Burners f Detection and itiatin Devices Alerting Devices No. of Ranges No. of Air Cond. otaTonalf No. of Waste Disposers eat Pumpnn��JT Self-Contained Totals: tion/Alertin Devices Otherg ❑ ❑ No. of Dishwashers Space/Area Heatin KWMunicipal Connection No. of Dryers Heating Appliances K/ SecuritySystems: No. of WaterNo. of No. of Devices or Equivalent No Heaters KW of. Data Signs Ballasts No. evices . of or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Atrach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete: FIRM NAME: WI LL /q Iq A/CWA4A/�l LIC. NO.: Licensee: jjy/(,L/AA4 l(/EWHqlV Signature LIC. NO.: (If applicable, enter "exempt " in the license number line) Bus. Tel. No.: Address: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L lc. 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 oneZ owner ❑ owner's agent. Owner/Age Signature Telephone No. �TF PERMIT FEE: $ 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 tmtil 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 nwnber(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, notthe 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 numberlisted below. Self-insured companies should enter their self insurance'iicense number on the appropriate tine. 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 permittlieense number which will be used as a reference number. In addition, an applicant that must submit multiple permiVlicense 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 flog 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Telephone (978) 688-9545 Gerald A. Brown Fax (978) 688-9542 Inspector of Buildings d, HOMEOWNER LICENSE EXEMPTION Pleaseprint DATE: JOB LOCATION: A] . M O )Q -P IS STIz1�6T Number Street Address Map/Lot HOMEOWNER ANWA+ 5gWwN MRM LS T NOR S4F8 Name Home Phone Work Phone PRESENT MA IMG ADDRESS oZ IV1 U 9,KA S 9 7 -)0607 - AJ 09,T 7060T AJ09,T 1 A Al O ova k79 J/ M City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family st><uckm. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. n HOMEOWNERS APPROVAL OF BUILDING OFFICIAL ' Revised 10.2005 Form Homeowners Exemption 130:\RD c1F \PPF:\1_S 688-95=11 C0N%,ERV.\TU_l` 638-95.30 HEALTH 03-95.30 PLANNING (88-9535 clM 711s K s J i a D amp at/KcaI 4s /arf room oaj-S� /awas � C o.,, 1J cc Apr rf ook— l5- 0 m jGrr room overAQad I17kh ) ogre outliQt-ol) iIISIZ wall C5� on p eAjway ou.tle.�scloser /,�kF /ar1e room ms/Gl2 I Utd te15 IS oor loofa li�AfS wd/� a112ay li hf� � 4 a� d -#et 4�91 laced. a sinq�2 l7��� �iX�1c�S %o Gm s4-alrs and earage-- nj �2n�Q�ninq SsnQ�� baA fix4u,,PS ori c6wns4irs 0-lrcLuf wilt be- %rti1GUed lrcc c i lS o►'2 C rJ✓►h ecf2G{ , 42 kided Mo -✓v smolo-10 dcjec-6, -/z3 �Qxlsfn9 de-tec-tor 1►'1 O PGS u. -f l,.fU ; ooln C�ooy a. � Wiri n s ti wci I i IV- -% swifek Lcx � ffcm � 9 y � r s in '✓'eco _-4 Location No. /3 a Date Cl - % D 3 TOWN OF NORTH ANDOVER 16692 3�3 J D 330 Building Inspector F A 9 + Certificate of Occupancy $ 70;, � s�CHUs6 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r &5. Check # 16692 3�3 J D 330 Building Inspector pJ p V F, 04 0 a o s ao'��� oLLI a) Lo w 11) (� Q o a- y N Q j 0 p C9 W t ~ I F- Z � •- a 00 x 0 o w w 3 0 6��'y0y+ O�5 m W OU _ z W Lo n N 0 a w X100 PR a D U o0 O In O N II II z a o w �- � r U Q II o jrwLL � vFio Q J Q °••' CO O� IX .. Y< w Q 0�z w(A vii L �, W m w 0 lel H U Q - N w cn p a �+ p_ j Z U 64 a m U a >- N Q Z 1 fY J O r, N Z Ld O a m Z w Q X -w p � W a z W a ^N cn aL.L o �`' wuj =� Q Z Q 1 w J O (nw-i >. O O F w w _ J Z Q p Q U 0 z wL.Lo UZ Q W J N ap�O—0 l 24' \ o, ca A . Z \ et cc 32.5' cir- C) O f o r6 w o \ C) 28° 20. t' to 30.47' 0 0 J \ g 0 aLocation /kID81S �No. 430, Date 8, a 6 a 3 0 NORTp TOWN OF NORTH ANDOVER 0 # i Certificate of Occupancy $_ ""'°''<� s�sE cwu Building/Frame /Frame Permit Fee $ 9 Foundation Permit Fee $ /D O Other Permit Fee $ TOTAL $ ' Check # &3 6648 Building Inspector ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING, aa. BUILDING PERMIT NUMBER: DATE ISSUED: 5 _, C A A SIGNATURE: Building Commissioner/IEEeLxtor,orBuildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: A'arl''s r y �/? - �/,? ,/4Q /Y- /„ r Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ar s Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.GL.1... 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record � s ��.G �aio 7�� Name(Print) Address for Service Silfriatiir Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 0�. a S�Z�z .4�z Licensed Construction Supervisor: License Number 76,---7a 4 / 1(/ / r�� Addres /- 0e,2`,5" Telephone ,- 9 C "f- Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable r Company Name Registration Number Address Expiration Date Signature Telephone ou M X Z O SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25cf61 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 ...... V No ....... ❑ SECTION 5 Descri do f Pro' osed Work check all applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: .S' �1 r.5; lla A ts/ a Sial( UIU40. SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant 1. Building` 100060 (a) Building Permit Fee Multi lier ... r> d,f a S tz ml 4 -OSS re 2 Electrical 60 d (b) Estimated Total Cost of Construction GOO. 3 Plumbing 0 Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 6 Total -(1+2+3+4+5 j A.0 0 0 Q' Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR FOR BUILDING PERMIT %APPLIES as Owner/Authorized Agent of subject property Hereby authorize 5/ to act on Mybe if i 11 matt rs r r uthorized by this building permit application. <i natu e of Owner Date SECTION 7b OWNER/AUTHORI/ZffED AGENT DECLARATION 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 ure of wner/A ent Date NO. OF STORIES SIZE _Z41 BASEMENT OR SLAB {� SIZE OF FLOOR TIMBERS / 1 sT 2 Q 3RD SPAN 1311, DIMENSIONS OF SILLS ,2 ,k—/V DIMENSIONS OF POSTS IF DIMENSIONS OF GIRDERS 0 HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY e IS BUILDING ON SOLID OR FILLED LAND p ,' IS BUILDING CONNECTED TO NATURAL GAS LINE nl -i < m O In al o m O Z : O _ :r v* 0) -2 M iAZ C S S y H � -1 N � � (Dm00 a �> > >�oc 3 m 0 Mn G O (D0 M 7 y 0 m 3 ' (D ° -� rt� r O -� M C. Q �' M-%cr a cD o. O M c0 ti/ o cD n r- -1 > m CL CL d 0) '" 3 C� O o '� 0 > > ° �. `Q' E< _� o a11111111 IIIIIIIIIIIIIIIIIIIIIllililililljllI E o O ��� a Z **�" rp�� cD r. M D U3 aj'O CD vj o ! a N fD CD _11 d D o r� o Ea A A :b 'O a 3ool —F \°' O cF CD s D :. .� o G(DCD �, O CL 00 oC.` :� —■� C. :� Lki C/) M m Cf) 0 m a— d y C) C Z CA CL � O CL= CO) O 0 v CD CDCL o c�=T"Cd CD CD o C O V�• av y -• Cl ca C S- CO) O CD Z CD O CD O CD c?�O m S -• y O Q N SGO C m y , _ � o 0 m C7 CD yciaC 3 m Z • CD =rN •_i 0 P:m Ceo• T o a o m p y W o � m • `,o S Ce OO O C) CA GO CD C— r r� L o :V 0 = m m c'n^ a: V oO ` 01 ca .T1cn O. ° m y Cn y o UCD o� m cn Z W a -o o CD cn cn / c G = o 2 ns o k z 0 rn m .: y 09 0 c rn " ti M - w x o m C'' o b o M a n z o x ° a. o 0 o n cp ti 0 CL O x m .: y 09 0 c FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fron, 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 APPLICANTS PHONE - LOCATION: Assessor's Map Number / PARCEL SUBDIVISION LOT (S) I STREET ST. NUMBER_Z CONSERVATION A[ COMMENTS TOWN PLANNER COMMENTS `OFFICIAL USE ONLY �►** AGENTS: DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS PUBLIC WORKS - SEWER/WATER CO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9W jm DATE APPROVED. DATE REJECTED TE Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3) WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS / DECKS , 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) 4) DEBRI REMOVAL FORM 5) WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION 2) FORM U 3) GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the -board of appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with application. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits frog! 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*********** *****—** -***—*- APPLICANT �%�� %✓tet `P yj ��,�� PHONE 7 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET ST. NUMBER ** ******y"OFFICIAL USE ONLY ►�*�*,� I RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED. DATE REJECTED PUBLIC WORKS - SEWERAVATER CONNECTIONS. DRtVEP/E'/RNTIT FIRE DEPARTMENT Ct of - r RECEIVED BY BUILDING INSPECTO Revised 9W jm ,�03 TE Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3) WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS / DECKS 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) 4) DEBRI REMOVAL FORM 5) WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION 2) FORM U 3) GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the board of appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with application. MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.0 CITY: STATE: Massachusetts HDD: 6027 CONSTRUCTION TYPE: 1 HEATING SYSTEM TYPE: DATE: 8-10-2003 DATE OF PLANS: TITLE: COMPLIANCE: PASSES Required UA = 419 Your Home = 385 or 2 family, detached Other (Non -Electric Resistance) Permit # Checked by/Date COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The.heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4. Builder/Designer Date Area or Insul Sheath Glazing/Door Perimeter R -Value R -Value U -Value UA ----------------------------,.___-___-------__ ____-___---_-_______-------- CEILINGS 1272 30.0 0.0 45 WALLS: Wood Frame, 16" O.C. 2222 13.0 3.0 158 GLAZING: Windows or Doors 330 0.350 115 DOORS 21 0.350 7 FLOORS: Over Unconditioned Space ------------------------------------------------------------------------------- 1272 19.0 60 COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The.heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4. Builder/Designer Date MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.0 DATE: 8-10-2003 Bldg. Dept.l Use I I CEILINGS: [ ] I 1. R-30 I Comments/Location I ( WALLS: [ ] ( 1. Wood Frame, 16" O.C., R-13 + R-3 j Comments/Location WINDOWS AND GLASS DOORS: [ ] I 1. U -value: 0.35 I For windows without labeled U -values, describe features: I # Panes_ Frame Type Thermal Break? [ ] Yes [ ] No i Comments/Location I I DOORS: [ ] ( 1. U -value: 0.35 I Comments/Location I j FLOORS: [ ] 1. Over Unconditioned Space, R-19 I Comments/Location j AIR LEAKAGE: [ ] I Joints, penetrations, and all other such openings in the building I envelope that are sources of air leakage must be sealed. Recessed j lights must be type IC rated and installed with no penetrations I or installed inside an appropriate air -tight assembly with a 0.5" I clearance from combustible materials and 3" clearance from insulation. I VAPOR RETARDER: [ ] I Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. I I MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be I provided. Insulation R -values and glazing U -values must be clearly I marked on the building plans or specifications. i I DUCT INSULATION: [ ] I Ducts in unconditioned spaces must be insulated to R-5. I Ducts outside the building must be insulated to R-8.0. I DUCT CONSTRUCTION: [ ) I All ducts must be sealed with mastic and fibrous backing tape. j Pressure -sensitive tape may be used for fibrous ducts. The HVAC system must provide a means for balancing air and water systems. I TEMPERATURE CONTROLS: [ ] i Thermostats are required for each separate HVAC system. A manual I or automatic means to partially restrict or shut off the heating [ ] I Rated output capacity of the heating/cooling system is I not greater than 125% of the design load as specified j in sections 780CMR 1310 and J4.4. - I I MISC,REQUIREMENTS: [ ] I Refer to 780 CMR, Appendix J for requirements relating to swimming I pools, HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F, and circulating hot water systems. ----NOTES TO FIELD (Building Department Use Only)------------------------- – The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 7 Boston, Mass. 02111 Workers' Compensation Insurance Affidavit - Please Print Name: S I L'V L- -SM01.4iC Location: 7DSL City //, 4-4(0f )4-,/t 01PIr Phone ( 970 �dpS 0 am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity lilI am an employer providing workers' compensation for my employees working on this job. Company name: 0' 57b1/r 6101x&114 Address 5'19297Ls /;-s /)4&i't, City elf �l 0/ � Phone #: ,�"h -J Z7 Insurance Co. 4$J-6GMZLd ek, •W4SLS Policv # vb/(f ( a d ?6 0 2— Address Address 7 6 City: It'l-i_ ✓y% Phone #: Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) 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 verification. i do herby certify under tP6 pains Signature, the information provided above is true and correct. Print name 5 /W61 Phone # Y- � FryYY/ Official use only do not write in this area to be completed by city or town official' ❑Check ii immediate response is r(egquired Building Dept Contact person: , ;7te 4 c J A-10 Phone i FORM WORKMAN'S COMPENSATION El Q76P ❑ o Building Dept Licensing Board Selectman's Office Health Department Other WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts NCCI NO 26158 • (800) 876-2765 ITEM 1. The Insured Steve Smolak POLICY NO. I VWC 6002880012002 PRIOR NO. I VWC 6002880012001 Mailing Address: 762 Dale Street North Andover MA 01845 (No. Street. Town or City County State Zip Code n ' ® Individual ❑ Partnership ❑ Corporation ❑ Other FEIN 01-5501765 Other workplaces not shown above: 2. The policy period is from 12/27/2002 to 12/27/2003 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies -to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under. Part Two are: Bodily Injury by Accident $ 10A , 0 0 0 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: See Endorsement WC 20 03 06 A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates - KIND AUDIT Estimated Per $100 Estirhated Code Total Annual of Annual No. Remuneration Remuneration Premium INTRA 259797 SEE EXTENSION OF INFOR IATION PAGE Minimum premium $ . 500.00 As indicated, interim adjustments of premium shall be made: ❑ Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly This policy, including all endorsements, is hereby countersigned by GOV GdV STATE CLASS 15437 KIND AUDIT kJ CLAIM OFFICE NAME CHECK SAFETY GROUP MA 2 WC 00 00 01 A (11-88) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. Total Estimated Annual Premium $ 500.00 Deposit Premium $ 517.00 MA Assessment Chg. $378.00 x 4.5000% $17.00 0'jo- 10/23/2002 Authorized Signature Date Internet Insurance Agency Inc 522 Chickering Rd, Rt 125 North Andover, MA 01845 License: CONSTRUCTION SUPERVISOR i Number: CS 053176 f , - Birthdate: 02/15/1958 Expires: 02/15/2005 Tr. no: 8131 Restricted: 00 STEPHEN M SMOLAK 762 DALE ST NO ANDOVER, MA 01845 Administrator • GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVERBUILDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the necessary information as requested below. Permit Applicant Property address -Map ! Parcel Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the building permit. Further I understand that my interpretation of the exemption status is subject to review by the Building Department and is only officially accepted when the building permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building. permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration or reconstruction of a dwelling in existence as of the effective date of this bylaw, provided that no additional residential unit is created. The lot(s) was / were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and or moderate income families or individuals, where all of the conditions of 8.7.6 are met and or represents dwelling units for senior residents, where occupancy of the units is restricted to senior citizens through a properly executed and recorded deed restriction running with the land. For purposes of this section "senior" shall mean persons over the age of 55. This application is part of a development project which voluntarily agreed to a minimum 40 % permanent reduction in density (buildable lots) below the density permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the planning board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a onetime exemption from the Planned Growth Rate and Development Scheduling provisions for thepurpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for a building permit ( all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that year. One building permit will be issued per year per Development until such time as the development schedule accommodates issuing building permits. Applicant must submit an approved FORM U with this EXEMPTION. PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS. BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED BUILDING PERMIT IS ALLOWED AN EXEMPTION AS CITED ABOVE. FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE CHECKING OFF OF A ABOVE EXEMPTION WHICH DOES NOT COMPLY, WHETHER DONE TO MY KNOWLEDGE OR NOT I GRO S FOR REFUS BY T UILDING DEPARTMENT TO ISSUE A BUILDING PERMIT. APPLI ANTS SIGNMftM DATE THIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978)688-9545 Fax(978)688-9542 Q cot. [ q Kk APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION ADDRESS LOT NUMBER IS-' SUBDIVISION DATE REQUEST FILED / Z - 2 - O -7 DATE READY FOR INSPECTION / � - /D - O TEN (10) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE CHAI SIGN ROUTING D.P.W. — WATER METER D I-"- —1 - TW DATE (Z - Z - 0 �;_ D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO THE INSPECTION REQUEST DATE. SIGNA / bfW AUTHORIZATION V 00 W 0 o W 09 t!) 0 Z LL O® Z W 3: oQ W V Is J aim t Bil M O CD v z a O � � c �a� cm c h �'a CD M m CL ~� CD O � CL) O O m O d Q. C Q y C +�+ C CcCc v J -0 . FL o CD e CD 0 CL �..7 CA ev r. • C cc Q. is 0 U) LU U) M W irW U) O uw 0 o C7 �• z a w° cin a w° U ww a w W o w 2„ a°' c:4 Q c4. cn cn M O CD v z a O � � c �a� cm c h �'a CD M m CL ~� CD O � CL) O O m O d Q. C Q y C +�+ C CcCc v J -0 . FL o CD e CD 0 CL �..7 CA ev r. • C cc Q. is 0 U) LU U) M W irW U) 0 ��m c y c � r c V V •O. L3O m ro U� s 0yM c .s r� m c �+J; H E m ' 0 3 cm c C y mi �m O C c yC : W O 04, m o con:a�� m �:cyQ r -:Q'c�o c c •O Q -)n �� '01m C 3o = ~ 0 OCL.: N N W0 •0.. m O r o =. oy- "... O .y ev C F- V -� CL= CCO Oo Z �.0 aO a COD C m� zoo 0� x y'o 0 H r $ nwm M O CD v z a O � � c �a� cm c h �'a CD M m CL ~� CD O � CL) O O m O d Q. C Q y C +�+ C CcCc v J -0 . FL o CD e CD 0 CL �..7 CA ev r. • C cc Q. is 0 U) LU U) M W irW U) Date .. It HOR,M 0f.`TOWN OF NORTH ANDOVER ye �. ��,ti0 I 3? ���o„ �. GL PERMIT FOR PLUMBING This certifies that .. .go t. e........ . has permission to perform .......... � . � ! .......... . plumbing in the buildings of ... ,/.�%? .c l� ................ at ...c--,. 0. le ... ......... North Andover, Mass. Fee. �� . Lic. No..//.5-68. �t 0 2 Z ! �i('... �.... . PLUMBING I SPECTOR P Check # 3-) 08 5737 MASSACHUSETTS UNIFORM APPLICATION FORAPERMIT TO DO PLUMBING (Type or print) _"loz NORTH ANDOVER, MASSACHUSETTS 5 �Date 9-')G—(33 Building Location , � 61�.-t Lice S` -Owners Name j f C� Permit # ` Amount S/ Type of Occupancy �' ��� / c(C �� ✓ /� New /7 Renovation 1:1 Replacement Plans Submitted Yes No ❑ FIXTURES (Print or type) Check one: Installing Company Name "/— & 7 El Corp. Address LI 19� 1_=(` 1:1 Partner mac, v ---vr ,;u A/ Busine one 4) °gs'r-z ­71--)_'VLiFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate Liability insurance policy r insurance coverage by checking the appropriate box: Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent El 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 ' stallations perf ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas usetts State PI mg e anjKapter 142of the General Laws. A --- APPROVED (OFFICE USE ONLY Type of Plumbing License icense 17inuer Master IT" Journeyman ❑ / Will MAI (Print or type) Check one: Installing Company Name "/— & 7 El Corp. Address LI 19� 1_=(` 1:1 Partner mac, v ---vr ,;u A/ Busine one 4) °gs'r-z ­71--)_'VLiFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate Liability insurance policy r insurance coverage by checking the appropriate box: Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent El 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 ' stallations perf ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas usetts State PI mg e anjKapter 142of the General Laws. A --- APPROVED (OFFICE USE ONLY Type of Plumbing License icense 17inuer Master IT" Journeyman ❑ Date... f —C- .q/— l) 3 S 1V O TOWN OF NORTH ANDOVER FO P PERMIT FOR GAS INSTALLATION 9 This certifies that ....3 u.!J ... ... ... . l�• . . has permission for gas installation .. tt �: .. w ..../`.'` . • ..? . . in the buildings of ... f!4 C (C . . . ....... , .. , at .... ! ..%�'���� ..... North Andover, Mass. Fee... . . Lic. No../� .� . `~ .D..t .... • .... . GASINSPECTO; Check # 3 ,DO 8 4452 7*4 v MASSACHUSETTS UNDDORM APPUCATON FOR PERMIT TO DO GAS FTrnNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations New Renovation ❑ Owner's Name Replacement ❑ Date � -,� (� Permit # Amount S Plans Submitted ❑ (Pmit� wiz or et -B G `— CD C Certificate Installing Company Name 6 Address //`4Ct:.O � 6'C�F4 - Partner_ Business Telephone p - ❑ Fin /CO_ Name of Licensed Plumber or Gas Fitter �CSji�,l� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent_ Yes No If you have checked yes, pleasecate the type coverage by checking the appropriate box- Liability oxLiability insurance policyEr 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: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent I hereby certify that all of the details and information 1 have sutbmrttea (or enteren) in aoove appncanon are tme arm 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 Ma Vac State GaAode 49d Chapter 142 ofthe General Laws_ ICity/Town OVED (OFFICE USE ONLY) " gnature of Licensed Plumber -Or Gas Fitter Plumber F -Y ❑ Gas Fitter TIMM um r easter E:] Journeyman H .A Date....(.>.�a� �. NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that -P Cif f r5 N `e C .......................................................................................... r has permission to perform .. `� .! "�' i� Q '�� '^" J� u � wiring in the building of �� v.�.n .............................................................................. at .....a ..........1!.Q..!!!..!. .......... ............. orth Andover, Mass. Fee ... 04. Lic. No. P.50J ...` :.2+ ELECTR AL INSPECTOR Check # -3 47v2 s� A A V& C09t0 ALgV0T 9I4,WAG7WSE` TS 'Department of P0& Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official -7Use Only Permit No.! ��— Occupancy & Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .All work to be performed in accordance with the Massachusetts Electrical Cade 527 CMR 12:00 (Please Print in ink or type all information) ate To the Inspector of -Wires: Town of North Andover / The undersigned applies for a permit to perform the electrical work described below. (- Location (Street & Number I ' \©l i '5t Owner or Tenant ) 1 A Owner's Address �6 A %.j C..) _ Is this permit in conjunction with a° building permit Yes tl' No 9 (Check Appropriate Box) Purpose of Building n-, (> U ' C Utility Authorization No. ® � Existing Service Amps Vats Overhead -0 Undgmd 0 No. of Meters New Service ` AmpsVoits Ovetttead ft' Undyymd 0 No. of Meters Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Work — Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 No. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Bumers Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges 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 Space/Are a Heatin KW Detection/Sounding Devices 0 Municipal 0 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 Massa a Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES O NO 0 have submitted valid proof of same to the Office YES C% NO 0 if you have checkedgS pl _ indigte thepW,of coverage by checking the appropriate box INSURANCE fVBOND 0 OTHER 0 (Please Specify). Estimated Value of Electrical Works (Expion Date) Work to Start Inspection Date Resquested Rough Final Signed under the Penalties p 'u 1: ` ! '� ` FIRM NAME r"� � IG�Cs� r+ I\ LIC, NO* Licensee �� , -r�`� Signature LIC. NO. O 6 CBus. Tel No. Address G tnri _ /I {' Alt Tel. No. kyxS t/ c OWNER'S INSURANCE WAIVER: t am aware tAat the Licens s 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) Telephone No. PERMIT FEE S_ (Signature of Owner or Agent) WE C05WW0jNWE,4LW0T9r[ASSAMSETTS Department of ru6Cu Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official Use Only Permit No. 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) ate 3�- 4 To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number -Ono r � y` l s � Owner or Tenant S 4 P v `Q Srt t G Owner's Address Is this permit in conjunction with a building permit Yes 9 -' Purpose of Building S / n� I C WL , - 1_ye - Existing Service Amps Voits New Service 89c� Amps ---a Voits . Number of Feeders and Ampacity Location and Nature of Proposed Electrical No 0 (Check Appropriate Box) Authorization No. ( -? o l �J' In, ` Overhead 0 Undgmd 0 No. of Meters Undgmd 0 OTHER: i I INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES c% No,o have subm"vaydrproof of same to the Office YES c% NO 0 If you have ch,YES please indicate the type of coverage by checking the appropriate box: INSURANCE Ow BOND 0 OTHER n (Please Specify) �� S� 0 (Expiration Date) Estimated Value of Electrical Work$ Work to Start r Inspection Date Resquested Rough Final Signed under the Penatti pe 'ury: FIRM NAME ✓Z v ✓ LIC. NO. Ucensee r t s cis' _ ✓ Signature LIC. NO. la - Bus. Tel No. Address C�Ct S s` n Alt Tei. No.J� OWNER'S INSURANCE WAIVER: t am aware that the Licenses doed'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 bent (Please Check one) Telephone No. PERMIT FEE E� (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 No. of Lighting Fixtures Swimming Pool gmd 0 grnd 0 Generators KVA No. of Emergency'Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices 0 Municipal 0 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: i I INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES c% No,o have subm"vaydrproof of same to the Office YES c% NO 0 If you have ch,YES please indicate the type of coverage by checking the appropriate box: INSURANCE Ow BOND 0 OTHER n (Please Specify) �� S� 0 (Expiration Date) Estimated Value of Electrical Work$ Work to Start r Inspection Date Resquested Rough Final Signed under the Penatti pe 'ury: FIRM NAME ✓Z v ✓ LIC. NO. Ucensee r t s cis' _ ✓ Signature LIC. NO. la - Bus. Tel No. Address C�Ct S s` n Alt Tei. No.J� OWNER'S INSURANCE WAIVER: t am aware that the Licenses doed'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. 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