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HomeMy WebLinkAboutMiscellaneous - 22 PROSPECT STREET 4/30/2018 32�- 22 PROSPECT ST 210/081. BEET 0000.0 - - f North Andover Board of Assessors Public Access Page 1 of 1 pORTM North ®allover Board of Assessors '... MOW A I •i 4• aroperty Record Card Click Seal To Return Parcel ID :210/081.0-0032-0000.0 FY:2010 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales4?vv f _ Summary Residence Detached Structure , a �[ Condo 22 PROSPECT STREET Commercial Location: 22 PROSPECT STREET Owner Name: LAMBERT TRS,K A&M M 22 PROSPECT STREET REALTY TRUST Owner Address: 22 PROSPECT STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 0.20 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1305 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 291,500 318,600 Building Value: 132,100 143,400 Land Value: 159,400 175,200 Market Land Value: 159,400 Chapter Land Value: LATEST SALE Sale Price: 1 Sale 09/20/2001 Date: Arms Length Sale F-NO-CONVNIENT Grantor: KENNETH LCert:Doc: : LAMBERT dBook: 00108 Page: 0145 http://csc-ma.us/PROPAPP/display.do?linkld=1516211&town=NandoverPubAcc 8/30/2010 Residential Property Record Card PARCEL_ID:210/081.0-0032-0000.0 MAP:081.0 BLOCK:0032 LOT:0000.0 PARCEL ADDRESS:22 PROSPECT STREET FY:2010 ' PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 00108 Road Type: T Inspect Date: 07/22/2004 Tax Clss: T Sale Date: 09/20/01 Page: 0145 Rd Condition: P Meas Date: 07/22/2004 Owner: - ea: 1305---- - Entrance: C LAMBERT TRS,K A&M M Tot Fin Ar _-_Sale Type: P Cert/Doc: _ Traffic: _ M - 22 PROSPECT STREET REALTY TRUST Tot Land Area: 0.20Sale Valid: F Water. Collect Id: RRC _ Grantor: KENNETH LAMBERT Sewer: Inspect Reas: M Address: 22 PROSPECT STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: RN Tot Rooms: 5 Main Fn Area: 1305 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4 - - T Method S Ft - Acres Influ-Y/N Value Class Story Height: 1.00_ Bedrooms: 2 Up Fn Area: Bsmt Area: 1305 Seg Type Code Sq- Roof. G Full Baths: 1 Add Fn Area: - Fri Bsmt Area 1 P 101 S 8518 0.200 159,439 Ext Wall: WS Half Baths: Unfin Area: Bsmt Grade: VALUATION INFORMATION Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 1305 Current Total: 291,500 Bldg: 132,100 Land: 159,400 MktLnd: 159,400 Foundation: CN Bath Qual: TRCNLD: 132086 Prior Total: 318,600 Bldg: 143,400 Land: 175,200 MktLnd: 175,200 Kitch Qual: T Eff Yr Built : 1975 Mkt Adj: Heat Type: HW Ext Kitc_h: Year Built: 1965 Sound Value: Fuel Type: O Grade: A Cost Bldg: 132,100 Fireplace: 0 Bsmt Gar Cap: Condition: A Aft Str Val 1: Central AC: N Bsmt Gar SF: Pct Complete: Att Str Val2: Aft Gar SF: 330%Good P/F/E/R: /100/100/78 Porch Tyne Porch Area Porch Grade Factor S 90 E 100 W 120 SKETCH PHOTO W 330 S 1A20 .FtI. zz zzn 45 GIM r� �g 1[ti00 .Ft . - FM/13 is 1305 Sq.Ft 9 90 5 t Z9AS - I� r� 22 PROSPECT STREET Parcel ID:210/081.0-0032-0000.0 as of 8/30/10 Page 1 of 1 '01 Locationc;,/C,/- No. Date t0ffTjj TOWN OF NORTH, ANDOVER + 41 s Certificate of Occupancy $ Building/Frame Permit Fee $ "us Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 18628 Building lnspecto'r*" ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING y � use �q BUILDING PERMIT NUMBER. DATE ISSUED: SIGNATURE: - Building Commissioner/InEeEtor of Buildings Date r SECTION 1-SITE INFORMATION 1.1 Pr Nly Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use .Lot Area s Frontage ft 1.6 BUII.DING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re tared Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record > ev> eel ITame(Print) Address for Service Signature Telephone 2.2 Owner of Record: N me Print Address for Service: M Signature Telephone 170 SECTdON 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ P3ompany Name t 3 i Rel � le �r Registration Number rm Address l jA Expiration D G) Si a re Telephone f i SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) I 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 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: x MI SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be "bQFFICIAL`USE ONLY Completed by permit a_p licant 1. Building /, j pf) (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 1, 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 1, ,as Own r/Authorized Agent of s bject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief C vriiqt Name Si Jkre of ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3RD SPAN DRvIENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS 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 Board of Building Regulations and Standards License or registration valid for individul use only ice= HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: Board of Buildin Re uiations and Standards - = 9 1 7/200 One Ashburton Place Rm 1301 - •: Expiration:.?/7/2006 Type: DBA Boston,Ma.02108 CASTRICONE ROOFING&SIDING CO. I Mario Castricone 31 Court St. %G. a fA N.Andover,MA 01845 Administrator: Not valid without signature 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 at: 13 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 . I OA. The debris will be disposed of in: (Location of Facility) r ignature of Permit Applicant Fire Department Sign off. Dumpster Permit i LI D to f Department of Industrial Accidents Odea of Investigations k9i 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Auulicant Information Please Print Legibly Name (Business/orpnizationlndividual)• ' r' Address: City/State/Zip:, &" ,ACf-- Phone#: ' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employee's(full and/or part-time)." have hired the sub-comactors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t ?• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5• ❑ Weare a corporation and its . ❑ Electrical required.] officers have exercised their 10. re-pairs or additions 3.❑ 1 am a homeowner doing, ,an work right of exemption per MGL 11 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] J 1 13.❑ Odier *Any applicant that checks box#1 must°also fill out the section below showing their women'compensation policyt infiondion Homeowner who submit tbis affidavit indicating they sit doing an work and then baa outside coutrctors must submit a new effidevit indicating such: tContractors that check this box must attached an additional sheet showing the using of Ste sub-oormaetom and their wo*as'comp.policy iufonrss"M I am an employer that is providing workerscompensation insurance for my employees. Below is the po&y&"Job slit information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: ' 1 Job Site Address: a, /d.G��:® y �(? City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policynumber and expiration date). Failure to secure coverage as requiref 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 bVrisonment,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. I do hereby certify ander the pains and penairks of perjury that the information provides above b teat and correct S tuTJ Phone#: __1o!2 4 ;2 Of'ldd use only. Do not write in this area,to be eompkted by eby or town officid City or Town: PermWLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cky/I'own Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone M: lniormaliun AUU i113L]i UtAIIJ11.13 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 undei 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 all 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 shidl withhold the issuance or renewal of a license or permit to operate a business or to construct buildings to the commonwealth for any applicant who bas not produced acceptable evidence of compliance with the insurance coverage required. Additionally,MGL chapter 152,125C( )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 tn your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not requited 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 munber on the appropriate lime. ' 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 permittliceme number which wig 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 has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The 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 as 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 #617-727-4900 ext 406'or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www-magg,gov/dia NORTH Town of � I No. - A dover, Mass., 14Q . 3 COCHICHEWICK A�RATEO S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ r.......... .. ................... Foundation has permission to erect........................................ buildings onp7.�.........(;?A-me-4 ..r Rough to be occupied as.. .. ..... .. Chimney ........................................................................................... ................ ................. provided that th person accept' g this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provision of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL.INSPECTOR UNLESS CONST"RUC"TION ST'ART'S � Rough .............................�/� f.00 ... Service . .... ................. ... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. REPAIRS CASTRIC®NE CONSTRUCTION LLC FREE ESTIMATES CASTRIC®NE ROOFING & SIDING CO. • Telephone: (978) 182-4266 s Fax: (978) 794-0910 MARIO CASTRICONE • DAVID MICAL P.O. Box 441, North Andover, Mass. 01845 I/we,the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms, aannJd conditions, on premises below described: Owner's Name . /. Job Address . r . . . �. . . . . . . . . . . . . City 11,11// Z'e State���- . .� SPECIFICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Materials and labor to cost . . . j.�� . . . . . • , . . . . . .�. ,/�� ,� ;; • . ' . • . . . • . . . . . . • . . . . . . . . . $ . �! . . . . . Payable ✓ :47W Y and balance in monthly installments of $. . . . . . . . , . , each, pays eon . . . . . . . ,day of each and every month thereafter until paid in full (. . . . . .%charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner.Workmanship is warranted for one year. Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation and a completion as requested by the contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if permitted by law,contractor shall be paid by the owner(s),all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor;and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties. The undersigned warrant(s)that he is(they are)the owner(s)of the above mentioned premises and that legal title thereto stands of record in his(their)name(s). PROVISO:This contract shall be void and of no effort if credit approved of owner(s)is refused. There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is this contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Cover attic storage cleaning not included.Not responsible for ice back up,Not responsible for broken plants or rip-offs. Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the partes and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is i peration. IN WITNESS WHEREOF,thearties have hereunto signed their names this, P 9d C 20 , r Accepted: Sigma' .. .. . �,! ' .. . Owner (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) Signed , , , , . ` Owner Per . . " . Signed . . . . . . . . . . . Representative ' Date. .NU y 3802 40°T: EE '� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Ui ,SSCMUS c� r is certifies that : . . . . ✓. . . . . . . . . . . . . r ' lie has permission to perform. 1-?� .-' plumbing iff t e�buildings of . . . . . . . . . . ti at,. . .�:� .. . .. . . . .-- _North Andover, Mass. Fee4. Lic. No//-�.c f1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR x WHITE: Applicant . CANARY: Building Dept. PINK:Treasurer { moi' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING y I (Type or print) o? NORTH ANDOVER,MASSACHT�'S�� �j.�- S f Date Building Locations 02 }}�� Permit # � 0,97 Amount ,(i"70 Owner's Name 'K New0Renovation Replacement Plans Submitted FIXTURES Cn z w En a W F a � x w Atrix w w x w F d d F `� � d p�, 0. <n E■ SLRBM BAg1V©YT � ISE MOOR 21�I1 FIDOt 3RD FLOOR 4IH FLOOR 5IH M= 67H FIOOI2 7IH FIfM SIH FLOCK (Print or type) � p Check one: Certificate ��� Installing Company Name I ( �l��' e6FT�k�Q o Corp. Address �02 �--1r`lL `� Partner. ire LkjTh It) 14, � 3 a'4-d Business Telephone (�6 3 3 Pa Firm/Co. Name of Licensed Plumber: /j,OYe!'yl�ic%d Insurance Coverage: Indicate the a of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been mdde aware that the licensee of this application does not have any one of the above t three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac efts State Plumb' Code a Chapter 42 of the General Laws. By: Sign4,mre Or icense um er Type of PI mbing License Title /�5'T City/Town License Number Master LJ Joumeyman APPROVED(OFFICE USE ONLY Date... f ........................ NOR rN TOWN OF NORTH ANDOVER o m PERMIT FOR WIRING . o , SSACMU`a '- f'�', l This certifies certifes that .. �............ . .. .............. has permission to perform .... �./............... b .J wiring in the building of.........j"�,........L- ��lL T.' ........................ at....... ...................... .... ..............-�'":............... ,North Andover,Mass. ` Fee.... �� Lic.No. �r �f G'7..Y, ELECTRICAL INSPECTOR Check 7047 Uffieial Use n01� Commonwealth of Massachusetts Permit No. � Department of Fire Services .w Occupancy and Fee Checked O ul .. BOARD OF FIRE PR.EVENTiON REGULATIONS (Rev.91051 (leave 111,101;) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All u-ork to be performed in accordance xcith the Massachus us Electrical Cad`(1`tECI._S37 CNIR 12.01) (PLE•i.SE PRINT[IV ItVI:OR TYPE ALL IXFORM47 0M Date; //,-o.;�`0 (O Cite or Town of ��,Q / .�-�-� T:, fhc� fna�cwar t f=Wh-ex: Br this appIkation the undersigned_�,ives notice 'his or her intention to perform the electrical work described below. Location (Street & Number) Owner ar Tenant ��c�iLt� L .�� .� Telephone No. Owner's Address Is this pernlit in conjunction witit a building permit:' Yes. 0 14 0- to (Check Ap,proprinte Box) Purpose of Building Utility Authorization No. Existing Amps I Volts Overhear! tJndgrd❑ No.-of Meters Service p New Service Amps I Volts Overhead❑ L'ndgrd Q No.of Mcters Number of Feeders:tnd Ampacity Location and Nature of Proposed Electrical Work: 1AA awfYC.. Cant edon(if the t9lloariat¢dable taaay be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fanso. of Total Transformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA A oven- t E o mergency ig ing No.of Luminaires Swimming Pool Md. a arnd. � Battery Units 0 No.of Receptacle Outlets No.of Oil F?urners FIRE ALARMS Noy of Zones No.ors!}itches No.of.Gas Burners o.o et Initiating D an Devices Tol No.of Ranges No.of Air Cond. Tonsg No.of Alerting Devices No. of Waste D s osers eat Pump _.um_-er ons o,of e - ontatine P Totals: Detection/Alerting Devices No. or Dishwashers SpaceiArea Heating KW Local 0 Munictpaf 0 Other Cdnnection No.of Drvers Heating Appliances KW ecurity ystems: No.of Devices or Equivalent No. of Water No.of o.o Data Wiring. Heaters KW _ Signs Ballasts No.of Devices or E uivalent I No. Hvdromassa a Bathtubs No. of Motors Total HP a ecomm°un cations +nag: g No.of Devices or E uivnlettt OTHER: attach additional detail ij drsired.tar as regtriredby the hape'vior al Il lies. Estimated Value of Electrical Work: If'7 7, ___..._ When required by municipal policy.) Work to Start: As6f inspections to be requested in accordance with EIEC 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 proofof liability insurance including"completed operation'coverage or its substantiae equivalent. The t undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE B{ BOND [] _ OTHER Q (Specifv:) I certify,tinder the pains andpenalties ofperjury, that the itiformatiaq all this application it trite and compleie. FIRM NAME: ADT Security Se vices. Inca LIC.NO.: 1533 C License • g r �,.�; LiC, NO.:_ir�25�- - Si nntur �. (1/appticerble!.Neter, `'i�,rrtripiiit the 7tCcryisr fwntiier line.}-0 Bus.Tei. No ' Gl} gQ 90� Address: 18 Clinton Drive Hollis N.H.03049 Alt.Tel. No.: 693-,i94-193Q__ `Security System Contractor License required for this work;if applicable,enter the license number here:_<,5CS aSL, /r`% OWNER'S INSURANCE WAIVER: I am aware that the Licensee does mal liuve the liability insurance coverage normally • . .+.. .._.._ ..__... t_..1..... t t.....4........:....)hie rnnulrpmpnt t ata the frhe,+nne)l`_1 nwne i 'ii f owners agent.