Loading...
HomeMy WebLinkAboutMiscellaneous - 224 FOSTER STREET 4/30/2018 �,___ � 2�4 FOSTER STREE-�'r 210j�oa.�-oos� -0000.o --_,_ _ �� i 4 Date..... ......... NORTH TOWN OF NORTH ANDOVER 0 $I- p PERMIT FOR WIRING 4L ��SSACMUSEt U This certifies that ...............................................................CD C- .............................. has permission to perform ..... .............................................. % ..... 57 wiring ng in the building ..................................................................... &1e Sr at................ ... ..........................b.. . North Andover,Mass. 1 ks34 Fee..................... ........................................... . ......... ELECTRICAL INSPECTOR Check # 7294 Lommonwealrn or massamusetts Utticial UseUnly Department of Fire Services Permit No. 7 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 107 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) ' ' Foste, S� . 2:!ka dIOVSC Owner or Tenant a r j S Telephone No. Owner's Address Zq rdsfe/L Sf.. // Is this permit in conjunction w th a building permit?#Y5/Yes No ❑ (Check Appropriate Box) Purpose of Buildinggi$. C�Ale gr Ar '' Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No,gf Meters Number of Feeders and Ampacity % - awA 11 d Rd ('1, e I�' ' Location and Nature of Proposed Electrical Work: Prod tCIOC4terl 6e kfm NA;tj Nwe- �Nvv�°n�w --a 6oLA'g Inose. New ��uruy� rid -iW0,v�roM,o���� cyV Com letion of the ollowin table ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.o ota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- E] No.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection an Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pum -Number Tons o.oSelf-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local EJ 'PP' [:] Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.o Heaters KW ater o.o o.o Data Wiring: Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as regatired by the Inspector of 6Vires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: y9 Q ;Z 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 cov rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:) I certify,under tl a pains and penalties of perjury,that lite information on this application is true and complet . FIRM NAME: l LL ELectaic Co. Z7Vc• LIC. NO.: 503d Licensee:k)Agi( W So/kie S Signature LIC. NO.: SU3 (lj'applicable�1 enter"Yetin the lice e number lin .)`, Bus.Tel. No. 3'76S 97 Address: 7 7 w- �q l e-m 0 . Q 3Q 7 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety"S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ tvt da-11- s-- -7 /,-�l 7- �, /.J e . . . . . . . . . . . . i Of HORTh TOWN OF NORTH ANDOVER lip PERMIT FOR PLUMBING • s � a �l �O•+r,°•A��4h i -i This certifies that has permission to plumbing in the buildings of . . . .- . . . .' -�;� c.,, .t� at North Andover, Mass. Fee- .`��.L1c. Ne,5?0. PLUMBING SPECTOR Check # (..i' 7375 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS �-� C1 Date Building Location ,�.Z 4 rD$�k dT Owners Name �/�i//� �( �¢�Permit# ;Z ,-ZS Amount 7 Type of Occupancy New � Renovation rl Replacement E] Plans Submitted Yes No FIXTURES F a W FrA F W �,W] rA Frc, d� a frr W E" CA � a rA d d a a aCRd ca SHIM BASE M ISI:HIM Z. 2 1 M FLOQt 3M FIOQ2 �> 4IH H M 51R FLOIR MI RDOt 7IH FLOQZ SIH HDQt (Print or type) Check one: Certificate Installing Company Name HCl,.57/ 12 Q Corp. Address -S I °,r Partner. Business Telephone l�?� ,�(/�'(flo/d �]�Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate boa. Liability insurance policy n Other type of indemnity 11 Bond 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 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 Massachusetts Statey, mbing Code and Chapter 142 of the General Laws. Y By igna 31 Licenseaum er Type o Plumbing License Title ;�Zo VV City/Town icense RuNioer Master El Journeyman APPROVED(OFFICE USE ONLY FINAL CONSTRUCTION CONTROL COMPLETION PROJECT LOCATION: 224 Foster Street, North Andover MA NAME OF PROJECT: Pool House Restoration PROJECT NO: D1661 SCOPE OF PROJECT: Structural repair and support of existing structure I Robert K.Dai lg a P.E. of Daigle Engineers,Inc. submit that our office has performed the following professional ser- vices, as specified in Massachusetts State Building Code Section 116.2.2 and as related to the structural portions of the work: 1. Reviewed for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Reviewed and approved the quality control procedures for all code-required controlled materials. 3. Been present at intervals appropriate to the stage of construction,and complexity of the project,to become generally familiar with the progress and quality of the work, and determine to the extent practical and pos- sible the work was being performed in a manner consistent with the structural construction documents. To the best of our information,knowledge, and belief,the structural work has been satisfactorily completed in substan- tial compliance with the intent of the construction,documents. :4 DAIG-E a -ignature: STRUCTURAL No.28583 assachusetts Registration No. 28583 e9�n 9PGI$SE�ti9 ,��� Our observations during site visits do not relieve e ' actor or its subcontractors of their responsibilities and obligations for qual- ity control of the work,for any design work which is included in their scope of services(i.e.design delegation),and for full compli- ance with the requirements of the Construction Documents and applicable building codes. Furthermore,the detection of,or the fail- ure to detect,deficiencies or defects in the work during our site visits does not relieve the Contractor or their subcontractors of their responsibility to correct all deficiencies or defects,whether detected or undetected,in all parts of the work,and to otherwise comply with all requirements of the Construction Documents. NOTARY STATEMENT: Subscribed and sworn to before me this day of NOTARY PUBLIC faz'h 0? 1 MY COMMISSIO EXPIRES ON - D1661 CCA final 051707.dm Date.. .... .. Y NORTH Of TOWN OF NORTH ANDOVER t - PERMIT FOR GAS INSTALLATION �,SSACHUSES This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gasinstallation . . AL.�*. . . . . . . . . . . . . . . . . . . . in the buildings of .f-4<( !:! - . . . . . . . . . . . . . . . . . . . . . . . . . . at . ..�.� `!. �. a . . . . . . . . . . . . . . . . North Andover, Mass. Fee. Lic. No.. . :�.. _ . . . . . . . daASiNSPECTOR Check# 5727 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date 8/29 2006 Permit# Building Location 224 FOSTER ST Owner's Name ORIT GOLDSTEIN Owner Tel# 978 423 0202 Type of Occupancy RESIDENTIAL New W1 Renovation[] Replacement Plan Submitted: Yet Nt FIXTURES/ HN rrudgas line no � � � w z o x fi W x v� 7 F 0 p4 7� �a < N W < w p 0 a 00U) afa, W z ~ w F- a H > ° z o z o 60 x o 16 M w �D 3 A 0 a a > A a 0 tw SUB-BSMT BASEMENT v 1ST FLOOR 2ND FLOOR y 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street ZCorporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter- INSURANCE COVERAGE: I have a culiability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE ✓I No ❑ If you have ecked y2s,please indicate the type coverage by checking the appropriate box. A liability insurance policy R✓ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will beA' mpliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th neral Law . By Type of License: •plumber Signature of Licensed Plumber or Gas Fitter Title as fitter �Pf�j ®� •-Master License Number C� City/Town •-Journeyman APPROVED(OFFICE USE ONLY) P Date.................................. -DS t NORTH 1 ° t�".. '••"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUSE� This certifies that .... /L T4vo .. ................................. ........................................... has permission to perform .........4 ✓l 1 "�� ....... . .................... ................................. `�� C� wiring in the building of...........`................(P#4/... ..... 1 .............. ... � �................... at............ SDS r S North Andover Mass. L* L9c ;fie..................... Lic.NA—... .... ................. `<-aG� --�!- - ..... �LECTRICALINSPECT04, C�Sy Check # 5 � 3 � DEPART118~7YPOFPUIBMSAFFETY Permit No. BOARDOFFMPREVEMON SZM12120 Occupancy&Fees Checked APPLICATTONFOR PERNIl'l TO P ORMELECTRICAL WORK ALL WORK TO BE PERFORMED 1N ACCORDANCE W1TH THE ACHUSSTS ELECTRICAL CODE,527 CMR 12:00 Q� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date -3 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the elec al wo described below. Location(Street&Number) -;2 2 �/ . Owner or Tenant Owner's Address V 67 Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps� Volts Overhead a Underground No.of Meters New Service Amps Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tuba No.of Transformer Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generator KVA ground 1:1and ri No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlet No.of Gas Butner No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons B No.of Disposals No.of Heat TOW Total No.of Detection and 9 Pumps . Tons KW Initiating Devices No.of Dishwasher Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices _ No.of Dryer Heating Devices KW Local Municipal Other Connections No.of Water Heater KW No.of No.of sign Bailasis No.Hydro Massage Tubs No.of Motor Total lHPP OTHER 17 hnuataeCover�Ptttatentbdletegtti<er>ais Gert®llaws E ars>bHatialegtivaialt yBS NO It m & niWdv&ptoafefsamelDdrOffm YES fl}auhas dzd edyMplmitt�*OrtypecfamWb9 12 INSLRANCE 1 BCND OMM E] ft.**) BomdanDile Fstim*dVa1zofEbcmcdWhk$ WbikioStxt kzpeCmnDaleFgz*d Rcvgh Find Stg<tadun� Ptesofpt3jtlty iiRMNAME gJ Lioat9eNo Busile59TdNa dim AkTdNa OWMCSMJRAN EWAIVER,Iamawa dxtdieLm=dDesmtharelhemamnewmWa tsubsmriale#vWatasMiedbyM GffnWLaws ��thatmysigsleases'thsptazrntapp5catrnwawstll�stec}�a"at k,'lease check one) Owner 1:3 Agent Telephone No. PERMIT FEE S signature wn DEPAR 1 WOF BIESUM Permit No. BOAwoFF7REPnvFNIwRDGUlAT70 m7C&&w p Occupancy&Fees Checked APPUCAHON FOR PERNIJf TO PEMOI M ELECMCAL WORK ALL woRK To B o -X":12 O� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perforin the electrical work described below. Location(Street&Number) -:2 Z V Owner or Tenant Owner's Address 67 Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building I Utility Authorization No. Existing Service Amp8..�Volts Overhead Underground No.of Meters _ New Service Ampex volts Overhead Underground C3 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Trensforraen Total KVA No.of Lighting Fixtures Swimming Pool Above Below Oerterators KVA ground ground No.of Receptacle Outlets No.of Oil Burner No.of Emergency Lighting Battery Units No.of Switch Outlets No.of du Barron No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Toru No.of Disposals No.of Had Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW LocalD Municipal r7 Other Connections No.of Water Heaters KW No.of No.of Siam Bailasis o.Hydro Massage Tubs No.of Motor Total HP i '7 112 J/ _t Cbvaage:No lDdetagtirM C=2dL8M a aim 91dffghuWXCFbL)FinAA9Oor 0—ft arilszbdi WequiAin YHS NO &ftniladva1dptoofofsawlDdre0l>iae M$S ]Fyouhatiedv&dYES`pl= Qle4eo(w wWby BOrID � O�IFR � �fatseSptx>fy) EMrnWdvayDeofEkWc Whk$ baron Lepectionl)aleRegrsed FZh F d under Palaliestfptsjtry. NAME Na s gJ -41 r ,� ,''�Uoane b &jd=T1Na n AILTUNa SB4SURAN(EWAM3kla mmdxtdieLio wdoamtliaredrireua wwwrageorissuegrmhta5mpWbyMimdmCknadLa%s myVanondtisparnit icaowwawsdi;M*W at ase check one) Owner [:j Agent Telephone No. PERMIT FEE S ignature or uwner Date.4 .-. d� "ORTq14, TOWN OF NORTH ANDOVER 10 . PERMIT FOR PLUMBING �SSCHUS This certifies that ._r ---. . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to p( �rform,.!. . . ..t `�" ;. . . . . . . . . . . . . . . + plumbing in the buildings of . . . . . . .. �/ . . . . . . . . . . . . . h �II�F%/ at��-. t� . .�. � .���: . . . . . . .;: 1. . . . . . , Nprth Andover, Mass. Fee . Li c. No.-"'1"c ,...-. moo. . . . . . . . . . . . P.IUMAN INSPECTOR Check # 6283 MASSACHUSETTS UNIFO APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Locationagg Owners ame ,^ nZ; Permit# X6'3 Amount Typeof0cipancyL New Renovation Replacement Plans Submitted Yes 11 1:1 ❑ FIXTURES Cr od SR» R4S VEST • in aom ZD FI OR 3M F1.00R 4IH FI OR 5M FLOOR 6M FLOOR 7IH FLOOR SIH FLOOR (Print or type) �" l` Check one: Certificate Installing Company Name :©SE e� l 14 P—/y Ey 11 Corp. Address (C)E Y-zZP-�L V,\�) 'mak 5 38 Partner. A�i Business Telephone (�©3-2 3S''7Oa 4 Firm/CO. 1 Name of Licensed Plumber: 76 P—��\ Q.0_Y)(LAI Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy �j ' Other type of indemnity 0 Bond ❑ 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State mbi Cogan hapter 142 of the General Laws. By: Signature re of rcense um er Type of Plumbing License Title 0 Iq a 4 City/Town rcense Mumoer Master ❑ Journeyman APPROVED(OFFICE USE ONLY. �°��- �t�` , � �;��)�� Date.... ... ............j..... NORTH °���``° '•�"� TOWN OF NORTH ANDOVER O p PERMIT FOR WIRING ACHus� This certifies that has permission to perform .............................�l0 .�.� G ........L ........ wiring in the building of ,`t ' Z' w Z at...... .. .S 7`�/Z >.+.................. ,North Andover,Mass. Lic.No..N3k/%...... .�`:�C. -........ ELEcrR[cALINSPECrOR/-- Check # t. 5536 I tiL'(,'U1KHUN VVtAL JH UP dM&"(,L1UJL:11 J Office Use only DEPAR731FVT0FPUX1CS4FE1'Y Permit No. BOARDOFFMPREVEMONREGUL4TLONS5Va RL2-M r Occupancy&Fees Checked APPLICATTONFOR PEI;MI /rkdescrnibed RFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITHCHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical below. ` ' 9 Location(Street&Number) � -2—' � S�`-P� S- M V o Y I-zl Iq Owner or Tenant 'A 1' r wr Owner's Address 2 2 q r.S 7- <T.1 Is this permit in conjunction with a building permit: Yes No a (Check Appropriate Box) Purpose of Building f'LI-e- Utility Authorization No. Existing ServiceYod Amps /Zo�Volts Overhead 1:1 Underground �� No.of Meters New Service Amps Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work J, ;s b o�-4 r e No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures I„Z y Swimming Pool Above Below Generators KVA J roundground rl No.of Receptacle Outlets No.of Oil Burners / No.of Emergency Lighting Battery Units /;4t.of Switch Outlets -767 J No.of Gas Bumers o.of Ranges / No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW. Initiating Devices -7-1/3 Q No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained DetectiordSounding Devices No.of Dryers / Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs / No.of Motors Total HP OTHER• hLtta=CoW1age,Flus�ulttod�eregttnarter>Ls�Galaallaws IhaNeaamaYLiabllOyhmaarelblicyitichxfagCornplei Cove oriCs lequiv&I . YES NO IhaNest&fWdvafidproefofsame1othe0ffi=YES ffyouha%wired®dYFS,plt eirrk thetype0f0oVe[aWby NSURANCE BOND GH11 t (Plea9e Spec y) BOcafimDale tu / 6,q // Es1im&dVAxofDacbcalWcdc$ WO&IDSW j" IhT"cnD&Regtres10d Ratgll Fmal Signedunctr ePenalties FiRMNAME/ A-�' /� Limrws a Li =G/r�u X l/10 �`�s /�u �r a sig=n Li=W No /- ce 3 dV 7 7 Busi=Tel.Na Z'PY-S'— o, e'6 V—e CL /* AL Tei No. to d 3 7,1, S 9 JcZ DWI EWSINSURANCEWANER;IamawarethattheLioawduesnothavetheinstaanceaAw4Foritsab9rrtialepvalartasregtmedbyMasmdxlsGertetalLaws andthatmyag iahueen thispermitapplicationwa*c fmthiscegtmern I 'Please check one) Owner M Agent Telephone No. PERMIT FEE$ Signature of Uwne—r or gen 4 ' 1111Li I-LAA l►lVl V►►X-;dr�11 V1'1/1[1Lhafll,/lVULii 1 V "••"^'""•'•"•'1 DF.PAR7MEVI0FPUB1JC94FE7Y Permit No. BOARDOFFIREPRETNONSM7(MRl2Bfl —� � Occupancy&Fees Checked * APPLICATION FO.R PERM1' RM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WIELECTRICAL CODE,527 CMR 12:00 CLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date OS' Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electricaw. Location(Street 8t Number) rd S�.e� S4 /V G�Ott r Owner or Tenant r�� I' r, C,-, , Owner's Address 2 2 q .f l SST Is this permit in conjunction with a building permit: Yes No a (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Y� Ud Amps /zo�Volts Overhead a Underground 13--� No.of Meters "" ,ervice Amps Volts Overhead Underground 1:3 No.of Meters r of Feeders and Ampacity "-a' on and Nature of Proposed Electrical Work 0 - a 1-e ;1 6,,,1, e e Lighting Outlets No.of Hot Tubs / No.of Transformers Total f KVA Lighting Fixtures 9 Swimming Pool Above Below Generators KVA J ro grolnd Receptacle Outlets D No.of Oil Burners / No.of Emergency Lighting Battery Units Switch Outlets d SNo.of Gas Burners v f Ranges / No.of Air Cond. Total FIRE ALARMS No.of Zones Tons f Disposals No.of Heat Total Total No.of Detection and _ Pumps . Tons KW Initiating Devices —F6 Q f Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained / DetectiordSounding Devices f Dryers / Heating Devices KW Local Municipal Other Connections f Water Heaters KW No.of No.of Signs Bailasis ydro Massage Tubs / No.of Motor: Total HP R• CovQr�Putstattbthete�tritana�.sofNlaSsach>setlsGenaalLaws _ �� YY � � aitssub9atrial�quivalat YES NO Is>brrwdvafidpioofoF=reiodrOffice YES 4�-� r-T Yycuha%edrdadYES,pk=indic* rrypeefamWby d�adarlgthe box INSURANCE BOND p GIM p ��) EqiiafionDaie WodctoStaR US" Estirt>kdVakxdEacbxalwcdc$ hgxrimDaoeRegEsWd Rough FvW FIRMNAMBundErTePdakies6fP / // LioemeNa Lioertsee CGS C4 K/p J u 6� a icck sigtmue LiomseNo L 3 d'7 dp' 7 Busbn=TblNa CPY-S'- el yef pAt. x S4 L, . A,r-e i, r—e- t/� � 4a S 76 s'- 9 7,,4 e -'A'VER'S INSURANCE W Alt Tel Na AIVFR;I am awae that the Lioanse does mt have the irnurare oova�e orits slbsta�tial etlirivalalt as tegtrired by Massadli=ns Cxrlaal Laws .�,._stmyagna4neonthispearrtaQpfi�alwaivesthicregtma>�t (Please check one) Owner Agent a Telephone No. -P RMIT FEE$ Signature Of Wner Of Agent f L�1QG-C N9 Ok Z 5