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HomeMy WebLinkAboutMiscellaneous - 21 PATRIOT STREET 4/30/2018Location No. _ Date ��01 - TOWN OF NORTH ANDOVER O w M 9 a Certificate of Occupancy $ • i ; i ;�S'•^° '��' 9 Buildin /Frame Permit Fee $ sncMust Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ �a Check # 185'13 %" -Building Inspedoe Fo°R cu-er ,.s+ yEat�s C1 LoCID< TOWN OF NORTH ANDOVER r R BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI& RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: " DATE ISSUED: SIGNATURE: fa^ - Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Prope.0 1.2 Assessors Map and Parcel Number: 21� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required- Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Htstoric is ric : Yes N O 2.1 Owner of Record r� tkna.rint) Addres�Service VTelephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ � Lfcen Construction 'fu}iervi� / D License Number Adress / i 77 Exptrahon ate g to Sire Telephone x 3.2 Registered Home Improvement Contractor Not Applicable ❑ l Company Name Registration Number Address �,-3 i o5d D � Expiration Date Sign2;16ele hone T M Z 0 v n M SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Ir ' 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 .......❑ No ....... 0 SECTION 5 Description of Proposed Work check all a Ncable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition F'� Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of .Proposed Work: I`_ ' [My -AMM 11111!i all I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFIE''ICIA , USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical (HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT JI, 0 fill/ �i,�E�Aizd , as Owner/Authorized Agent of subject property Hereby authorize % to act on My behalf, in allers rel to work authorized by-fhis buildink permit application. Signature of Owner Date SECTIIO�N' 7b OWNER/AUTHORIZED AGENT DECLARATION I,as OwneAuthorized A— gen o bject r prol Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief e Si gri/t6rej-06,166wn A Date –�– NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS 1 2 ND3 RD SPAN •` DIMENSIONS OF SILLS Dff TENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH114NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH ANDOVER BUILDING DEPARTMENT • Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordajFe with the ro 'sion of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: 1) L Fire Department Sign off: Dumpster Permit Date Deportment of IndustrW Accidents Office of Investigations ky 600 Washington Street Boston, MA 02111 www.Mass:gov/ilia Workers' Compensadon Insurance AMdavit: Builders/Contractors/Electridans/Plui[ nbers ApipUcant Information Please Print Leidbly Name(Businessiorpnizatiorubdividualy Address: City/State/Zip:99a:2, �fi_ Phone #: 0' Are you an employer? Check the, appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 � loyees (full and/or part-time).• have hired the sub-eozracuirs 2. t<'J i am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] Officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § l K and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required) 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ©'building addition 100 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repair 13.❑ Other -Tiny appgsa& aw. caeca UUA IF i IIWr am Kul Out IDC iCOOn Oehow d'"lli(:tir WOAM' ep111POlintion pommy in bmisum t Homeowncis who submit this afrdsvit WScaNng they are doing so work slid then bee outside eoubsctors must submit a new affidavit is+dioa g such ZContrackm that check this boa mut attached an additional sheet showing the == cf the subaorioactm and the* wolkas, cMV- Poli' information. I ani an employer that U pmvMlrra rtw►kers I compewddon Imuranee jor my aa= Below L the palk y and job Bite lnforrttd" Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Dace: Job Site Address: City/Statcaip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requucf under 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 % 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 vaification. I do hereby �" that the irrjoPmedon provi6d eb@711 &7 ea ewre" i Qfflcid use only. Do not write In thb area, to be completed by clo or town offlCld City or Town: PermWUceen b Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone 0: kinui inakhviii alii%& ZuO&A Mvvav a.,i Massachusetts General Laws chapter 152 requires all employers b a provide workers' mpcnsatiou for their employees. is defined as "...every person in the service of another under any contract of hire, Pursuant to this statute, an enap/oya 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 ed in a joint enterprise, and including the legal representatives of a deceased employer, or the of the foregoing engag lo cess. However the receiver or trustee of ah individual, partnership, association or other legal entity, employing employ owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of tate dwelling house of another who employs persona 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 coy applicant who has act 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 b Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to you situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees outer than tate members or pumas, 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. Abe be sore to sign and date the aftidavk. 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 Acxideats. Should you have any questions regarding the law or if you are required to obtain a workers' convensation policy, please call the Department at the mmaber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. - City or Town OAlctuds 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 permittlicense number which will be used as a reference number. In addition, an applicant that aunt 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 dud has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid afiis on file for future permits or licenses. A new affidavit must be filled out each year. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would I&e 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 fans member: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www,mm.gov/dia 9 0 ,y33a'%s D 4 W M Cd n� z V w a c� a w a o w o pG r. x U G w a w o rx G w a w w o a: cii c ii U o c�4 c w rz.toz r� U) 0 cn z �m Cm COD 0 — r m CO CL y=•+ = O � 3� IN O I L C3 o a ME cMQ co o � c ec � .3.0 C Z ts 0 CL C.3 N3 c C C CL 0 LU YI U) V9 W W W U) c o ca o ` C N � ' C ' � O 0 C3 C. A W m c ;Z O O � • y � :Ea •0. c = i7 r.+ v d y0-. C : 0 • C2 1.2 r0. \: C • 1 me h r E v o � y y 0 •.. _m o Z I Ce O O_ :•L y Zr0 o a, • A :zz o � cm's Q y• 0 m V N O Z O _ o CL ca cc Q 0c _ • :•moo Q ~ 2 y m w � m COD W 0 �r�t Z •E c •- al `OE E az v Z a cm m��- 5 CO2 W ���� s � = ow CL �m Cm COD 0 — r m CO CL y=•+ = O � 3� IN O I L C3 o a ME cMQ co o � c ec � .3.0 C Z ts 0 CL C.3 N3 c C C CL 0 LU YI U) V9 W W W U) s�� N° 1 % v 4 Date..._ ......... .................. ° t ° ;•� "° TOWN OF NORTH ANDOVER i? � �, ... . • of p PERMIT FOR WIRING ACMUS� This certifies that . ...... ..............�........y'................................ has permission to perform............ y wiring in the building of ........... .. ....... .......... I....... - .............. . North Andover, Mass. Fee.. #5 0............ Lic. No.3%........................................................................ ELECTRICAL INSPECTOR 08/11/98 10:06 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer _ The Commonwealth of Massac`huse "" Only- _ Perch NO. G1 — Department of Public Safety Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 heave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Macsachusettc Electrical Code. S27 CMR 12:00 (PLEASE PRINT IN INK OE ALL INFORMATION) R TYP City or Town of r4,,,,Ao ' c The undersigned applies for a permit to perform the elec Date 7-7-5K To the Inspector of Wires: trical Work described below. Location (Street & Number) �/ L"il { 10 T J . 0 Owner or Tenant QD C L 2 G\C_ k eC V Owner's Address S(k#\U Is this permit in conjunction with a building permit: Yes ❑ No ® (Check Appropriate Box) Purpose of Building .J ir,t- ►^tii�V Utility Authorization NO. Existing Service /(56 Amps /,Z-0 Volts Overhead ® Undgrd ❑ No. of Meters New Service �00 Amps i �,n / ��0 Volts Overhead 19 Undgrd ❑ No. of Meters Number of Feeders and Ampaci Location and Nature of Proposed Electrical Work No, of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures SwimmingAbove In - Pool grnd. ❑ grnd, ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No, of Emergency LightingBattery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal ❑Other Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No. of pumps Total Total Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Si ns Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws r, I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO 0. _I. have submitted valid proof of same to this office. YES ❑ NO If you have checked YES,,please indicate the type of coverage by checking the appropriate box. �4 INSURANCE M BOND F] OTHER F-1(PleaseSpecify) .�.-� Expiration Date Estimated Value of Electrical Work S Work to Start ?-X-'70' Inspection Date Requested: Rough Final 6 —/o Signed under the penalties -qof perjury: -( / FIRM NAME SfCv2� `` Ln dv�,.(0�1^C'� OCC, �LIC. N0. 7 7 E Licensee Sm -,,e S�ig-'. gnature __)2C � •-✓ LIC. NO. Address �O`J �,, iUe �� !J T_ �-C��w .. /'Ida. (��c Y� Bus. Tel. No a7C�1 CS;' - `Da' Q Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please.check one) C' 00 Telephone No. PERMIT FEE S Signature of Owner or Agent REMARKS BY ELECTRICIAN: P!, Z N E O Z N w E a E O V REMARKS BY ELECTRICIAN: P!, Location No. Date '®g, ''\ Check # 15541 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL v wilding Inspe r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING P BUILDING PERMIT NUMBER: DATE ISSUED: 2e SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Prop Address: 1.2 Assessors Map and Parcel Number:: Map Number Parcel Num `r 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owes pf Record ° , t ame (Print) Address for Service 41422 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licens Construction Supervisor: Not Applicable ❑ r � Li ensed Constructio Supervisor: License Number AQAress 'on E ra Date ;i/91(,(Ua Te phone 3.2 Registered Home Im rovement Contractor Not Applicable ❑ ompany Name 1,12— ��, r Registration Number re Expire ion Date S' nature ---Telephone Ma M Z O 0 M 90 �i 14 SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. —Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 11 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: n I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant �,,..` � ' . OFFICIAL USE,'ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) V 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 Check Number JE(,11V1V /aVWAEKAU111VKILA11UN 1U BEUUMPLITEDWHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner uthorized Agef subject pro rty Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS OT 2 ND3 RD SPAN DIMENSIONS OF SILLS DIlvQENSIONS OF POSTS DIMENSIONS 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 /rc {%amrmraiau��a�;_ ��faaaczr�i�delta BOARD OF BUILDI G REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 018687 Birthdate: 01/04/1950 Expires: 01/04/2004 Tr. no: 13020 Restricted: 00 FRANCIS VALENTE 7 ZACHARY CROSSING SALEM, NH 03079 Administrator I a V North Andover Building Department Tel: 978-688-9545 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: 6 (Location of, j ility) Signature of Permit Applicant ��Q :�- Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Print 1 am an employer providing workers' compensation for rimy employees working on this job. ComRany name: Address Cifir. Phone Insurance Co, P_oa a name: Address G(ty: Phone #� Failure to secure coverage as require! under Section 25A or MGL 152 can lead to the trrtpositlon of criminal penalties. d a fine up to $1, s00.00 and/or one years• imprisonment as well as civil penalties inform of a STOP WORK ORDER and a fine d ($1110.00) a day against rne. 1 understand that a copy oP� statement may be forwarded to the Office of Investigations of the DW for coverage verification I do herby certify uncXrJde pains and the infonnation orovided above is true wdcorrect Date- #A9- 37 ate Print i ,, Official use only do not write in this area to be completed by city or town official' pcheck flinmediate response is required Building Dept Contact person: Phone RM WORKMAN'S COMPENSATION # i] Building J)ept 0 Licensing Board 0 selectman's office o Health Department 0 Offier ey eA A O z a H ti W H W V y n` C 0 y cm w m `m O C 0 .y .L- CL go r :moo :mc ' o i C N O C 'o V CL C Cum m C ;= O O i CD �Q m c co c o n H O m :oma C.2 jo• m C VJ Z_co m ;403 m CCI C � :C E d hCD CD H C O cm m O cm c 'c N CD 0 z C) CD •I fil I CD C! • L C y C V! Q m m CL 4D 0 CD 1-- CD Cl ca 0 CK CL CM< co M o Ca CL. o m Li CD CL C.3 c C C W 0 0 U) U) CCW w w U) 0 O O W W v -u w a c� A as b w aG U G w o0 a a4 w a � c1 w w: w w cn a H ti W H W V y n` C 0 y cm w m `m O C 0 .y .L- CL go r :moo :mc ' o i C N O C 'o V CL C Cum m C ;= O O i CD �Q m c co c o n H O m :oma C.2 jo• m C VJ Z_co m ;403 m CCI C � :C E d hCD CD H C O cm m O cm c 'c N CD 0 z C) CD •I fil I CD C! • L C y C V! Q m m CL 4D 0 CD 1-- CD Cl ca 0 CK CL CM< co M o Ca CL. o m Li CD CL C.3 c C C W 0 0 U) U) CCW w w U) ' N° 21559 Date ..... 71r-avv.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ......i'. ec 1 R has permission to perform .... {....!.`../.-AN.' t ...... ................. wiring in the building of ..... 7- c,, . r. .............................................. at ... 0.,..1 ........ P��. ie. �Al . ...... ........ :. .. .............. rth Andover, Mass. Fee..xjam.... Lic. No. ............ ......... . ...... ............... ECrRICA iN*'S*P—ECT0R Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer viIludi we vIny �C r Permit No. ✓ ac leaz 4;D -P& S klf# Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR all information 12:00 (Please Print In ink or type ) Date 6 To the Inspector of res: Town of North Andover The undersigned applies for a permit to perform theelectricalwork described below. Location (Street & Number Owner or Tenant "Y- Zar — X11" l Owner's Address R/ /"d�%�// 74 S %� 6 7Z Is this permit in conjunction wiit,ld ha building permit Yes/l No ❑ (Check Appropriate Box) Purpose of Building /J ZZ / �7 / /% 3,7 Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgrnd ❑ No. of Meters New Service _ Amps Voits Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 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 GE NO = have submitted valid proof of same to the Office YES = NO = If-YLLU have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) �q (Expiration Date) or Estimated Value of Electrical $ 0 y Q Work to Start 0- — � _ Inspection Date Resquested Rough / — 7 Final Signed under the Pemties,9f perjury L r FIRM NAME __. �/ / !//�YJ/ Sy f ZG��►"�� LIC.NO.,Q2f NO. /,fir Bus. Tel Address 4 G6%2T'Az�_,,,�(�%Y //Pr /e z- Alt Tel. No. OWNER'S INSURANCE WAIVER: I 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) Telephone No. PERMITTEE $ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA No. of Lighting Fixtures Above ❑ In ❑ Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di osal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices O ❑ Municipal ❑ Other s yJ%D 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 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 GE NO = have submitted valid proof of same to the Office YES = NO = If-YLLU have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) �q (Expiration Date) or Estimated Value of Electrical $ 0 y Q Work to Start 0- — � _ Inspection Date Resquested Rough / — 7 Final Signed under the Pemties,9f perjury L r FIRM NAME __. �/ / !//�YJ/ Sy f ZG��►"�� LIC.NO.,Q2f NO. /,fir Bus. Tel Address 4 G6%2T'Az�_,,,�(�%Y //Pr /e z- Alt Tel. No. OWNER'S INSURANCE WAIVER: I 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) Telephone No. PERMITTEE $ (Signature of Owner or Agent) Client#- 21012 TY 'NTT)n a ORn CERTIFICATE OF LIABILITY INSURANCE DAT0 09//05/05/D/00 PRODUCER Davis Towle Morrill & Everett POLICY NUM BER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 27 Rte 101A Amherst, NH 03031 A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CCP8599092 03/28/00 03/28/01 EACH OCCURRENCE $300 000 INSURERS AFFORDING COVERAGE INSURED Douglas E. Denis DBA INSURERA:Merchants Mutual Insurance INSURER B: D.E. Denis Electric. INSURER C: 29 Captain Seaver Rd. INSURER D: Brookline, NH 03033 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUM BER POLICYEFFECTIVE DATE MM/DD/Y POLICY EXPIRATION DATE MM/DD/Y LIMITS A GENERALLIABILITY CCP8599092 03/28/00 03/28/01 EACH OCCURRENCE $300 000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone tire) $100, 000 MED EXP (Anyone person) s5,000 CLAIMS MAIDEN OCCUR PERSONAL & ADV INJURY $3 0 0 0 0 0 GENERAL AGGREGATE s600, 000 GEN'LAGGREGATELIMIT APPLIES PER. PRODUCTS-COMP/OPAGG $600, 000 POLICY PRO-JECT LOC AUTOMOBILE - LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Eaaccident) $ >t BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) $ BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Peraccident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTOONLY- EAACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- OTH- TOR`LLI I S EMPLOY EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICYLIMI $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Liability Limits apply at inception of policy. L;tH IIFIL;AI t Bob Nicetta-Electrical 27 Charles Street N. Andover, MA 01845 SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Inspector DATETHEREOF,THEISSUING INSURER WILL ENDEAVOR TOMAI L] Q_DAYSWRITTEN NOTICETOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUTFAILURE TODOSOSHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANYKIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE to umu co -a Inwll 01: 2 4; J 5 y U 2 CM 0 ACORD CORPORATION 1988