Loading...
HomeMy WebLinkAboutMiscellaneous - 247 FOREST STREET 4/30/2018N) Location No. , Date NORTN TOWN OF NORTH ANDOVER O: ••�•n :•,1.00 i +4 • L 9 ' Certificate of Occupancy $ cMuBuilding /Frame /Frame Permit Fee $ �,E- 0a � s�st � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /o/ 18772 Building inspector • TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI$ RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 10" -stdm E�.ii:! BUILDING PERMITNUMBER: DATE ISSUED: SIGNATURE: 000' Building Commissioner/Inspector of BuildinNgs Date SECTION 1- SITE INFORMATION 1.1 Property Address: yr7 fora; 1.2 Assessors Map and Parcel Number: /06.,4 C0,3? Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Reqt1ired Provided 1.7 Water Supply M.C.I-C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 Zone — Outside Flood Zone 0 municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIPJAUTHORIZED AGENT r-itstoric District: Yes No 2.1 Owner of Record - 1'*,o D1) - fojm ;?V -7 F6 U-5 Name (Print) Address for Service: 1.1 zy Signature Telephone 2-V Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: .6,6 ;? C?- W 151 ow 0 Adrdrs aj ;, E)ZZ-CO— q7l"YOOS09� a Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor r,ff. Not Applicable 0 Company Name Registration Number Address qle Expiration Date Si nature --Tel e6hone T M Z 0 0 Z M 90 0 M z 0 r S i V 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 resgit in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... 1. No ....... ❑ SECTION 5 Description of Pro osed Work check A applicable) New Construction Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify IV L4eL- Vl Brief Description of Proposed Work: 1 %D 21 ` iffr�-,Ca002l' Pszc1l, I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIA)(:USE UNLI' c4 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) p U� D 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 I, ] )4&A _, as Owner/Authorized Agent of subject property Hereby authorize T6 be r+ C g IV,04 S W pow l 0 e D W 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 I, 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 PrXaae R Si4of caner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS I -IF IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE N m m m X m N F) m N� d CO) C7 'v O CD MZ y C36 =� O CL = CO) � O � v CD CDCL O Q CD CD O CD mm a C CD y. CD nO CO) UM CD a v y O 10 Z CD O CD O CD E A'A z r 0 C 2:-nO m = dN � m gym: m O N =300 m N C) m m : N m CLC Cf� N 'fir] p w n =r -c N '� .-f O ...r= "ILO N -�i 0. 3� CL = m ti CD �O N 0 O � •0: =r m a O� = : ••► a CD �. O Z�•C0.3 m =r CD go: 00• N = :0 CL": O m N ' 7 O m n 3 m so N cr C36 d C ':v w gym: m O N N : Cr1 m m : 'RC1 o A Cf� N 'fir] p w n ;v o 00 O l9 : r d .-f O 91 m 0. 3� CD =r: •0: Wi m: T N : a CD �. m CD go: 00• CL": � O Cn 0 Cn p7 �, ':v w 'JO C as :v wT F Cr1 "n ?r 'RC1 o A ,� r to 'fir] p w n ;v o 00 t7 C :1G R ' r d (n b cp 91 O a W W 0 G z a w 0 0 c FORM U - LOT RELEASE FORM y INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from 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 PHONE / 7 g`QQ LOCATION: Assessors Map Number PARCEL SUBDIVISION LOT (S) STREET ,�' 7 %5+ ST. NUMBER TION OFFICIAL USE ONL TOWICAOENTS: 'OW7 DATE APPROVED DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HE4kLTH DATE APPROVED -DATE REJECTED $ IC7NS ECTOR= EAL H`�� DATE APPROVED)r_ PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revbed 9197 JM ;­ 7 j A 14 } r! - I :te77. t - rm m I 2 -u E % .<\ d\' m m G) +«. \ /) Z > d 2 \ q = e r // z ƒ k xk3�� a , m / � //zk% o�0 / \| 0 / \ no < { kto � 2005 09:01 FROM:DEVINE MILLIMET BRNC 978 684 5054 TO:9784744785 _ P.,002/002_ htJh �OMIMJS4S►i P �---.� t No+LTN Ido"'A S. �l k�ttlaeljk% 0 301` A PROFESSION& I',MD SURV6 00 HERp_BY CERTIFY THAT ABOVE MORYGAQE INSPEO,! PIAN WAS PREP RED FOR �..- CONN£GiION WRI4ANFtiM M0A71 AND 18 NOT INMND£D OR HE 4FNTE0 .0 Be A MND OR PROP sae: 1 11 --100 AMERICAN SURVEYING COMPANY 77 Piumiotd Avolls, VIFali fro MAA 02154 p17) 893$477 Most In spa Plan bRIdINAL pE00ADF0 7 COI.INTY F1[ -l' ff" OP BOMB Tullt.acAT10N Of iM£ . 7s� jm!l I.G.Ce1t.• 5eCf fon 4 Storch Residence 247 s=orest Street North Andover, Ma. Box fear electriclet meter Details: Al framing lumber to be ##2 SYP or better Design live load -60 PSF Footings: 4 a@ 10" x 48" Support Post: 4" x 6" pt Anchored to footings secured to concrete Beam: 2- 2x 12 bolted to post Joists: 2x8 16" O.C. House band: with bitithane membrana barrier Lagged with 318" x 4112" galy every 16 inches Railings- WhIgh 4x4 post 2x4 top & bottom rail 2x2" balusters 4" spaced E. B- Genera(Contracting Specializing in AddhUns/Renovation Roofwg/Painting/General Carpentry 23 Boston Rd. Billerica, MA 01862 Telephone: 978-459-1578 PROPOSAL SUBMITTED To: Pant Storch PHONE H: DATE: 7/15/05 Fax#: STREET: 247 Forest St. JOB LOCATION: Same CITY, sTATE AND ZIP CODE: No. Andover, MA EsnmAToR: Sam Ayala & Bob Emmons CONTACT: we hereby submit specifications for: Installation of porch/deck. The 10X24 porch/deck will be installed as follows: Structural members will be of pressure treated material. All three footings will be spaced 12 feet from each other and four feet deep. Footings will be inserted with 12" sonic tubes. Pre -mix Sacrete cement will be poured into the sonic tubes with pads clips for the 4x4 posts. The Ledger board will be of 2x10 size. Aluminum Flashing will be installed behind the ledger board. The ledger board will be lag bolted onto the base of the home. All joists will be 2x10 and will be doubled at the skirt and rim. Joist hangers will be used to properly secure the structure. The deck will be of a composite material (Trex or equivalent) and secured using dimple resistant fasteners. Rails and Spindles will be pressure treated stock and cap. All workmanship will be in accordance with Mass. State Building Code and will be guaranteed for three years. Deck Price= $6,000 Installation of two windows and one door (Labor only) homeowner will do the finish carpentry as discussed. _ $800 W9 PmPose hereby to fiamsh material and labor — complete is accordance with above specifications, for the sum of Six Thousand Eight Hundred I DOLLARS $6,800 Payment to be made as wows: 1/3 deposit —1 /3 upon half completion 1/3 upon total completion. Authorized j�;�.??2;i�'/I.r Signatwe✓rLl,� ACCCptaflCC OfptYJp0Saa{ The above prices, spaci5cations and camditions are satisfactory and are �aecepted, You are to do the work as Payment will be made as outlined above.�� Date of Acceptance: Signature:' ,/ AU material is guaranteed to be as specified All work to be completed m a workmanlike marmer according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements are contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. 80" AM OF INK ARIWE Pau= a c"immum " m THE 6911ROWN WE INMEM. THE "KIM MAN -1 W&L SgWanp I* rva 19— CATS"mma mm TO I'M Cmplaw HOLO M WAM TO THE LEFT ON PALM TO WJL VIAN no, mmumnD awmam OR UAINUTT I AUTHORRED RDW&OWMam C ,�o I I t David 'T. Louis j — / I�L DL 04/14/05 ponim roll THE HOWE INS AGENCY Tm GERW=72 a 110000w ONLY No cowwa NO wmm UKO THE CEMVW ATE HOLOW TW CBMFC47E OM NOT AMM. OnM ON ALTO THE COVENAE AFFOFM By THE 4 PUNCHARD AVE p0LX= W.LOW. COMPWM AFFO� COVW*M ANDOVER MA 01810 COMPANY A ROBERT EMMONS JR DBA E B GENERAL CONTRACTING 16 PHILLIPS STREET OMP CAW TRAVELERS INS CO COMPAIVY c LOWELL MA 01854 comftw THIS M TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 INDrATEI). E iNAMM NAMED ADM FOR THE POLICY peuW CENT UWATE MAY BE OUSU CONDITION OF ANY CONTRACT OR OTHER, DOCUMENT WITH RESPECT TO WHICCH THIS EXCLUSKM AND aW HEREIN IS SUMOCT To ALL THE TERM. MAY''HAVE BEEN RFntiCQ) BY PAID CLAIM. CID Lyn T"I 00 111011UNGNIN A MMOWytI WWW AOGKGATE GDAVAL umam COMMIERCAAAL GENERAL UA@WTY mAemsmae F-1 occupt, 011110HEOM&CONTRACTOR1 PROT PRODUCTS - COMPW AGO PERSO"ft&ADVftJURY EACH OCCURRENCE HFIRE D^%A" Oft em ftj I MED VIP A" " ownni 4 All"11111111101" UNNUIT ANY AUTO COMMIED SNOGLE UWT ALL OVWAO AUTOS SCHEOULGO AUTOS IODILY 04JURY IPW pwaon) HIRED AUTOS MOt44YA"EOAUTOS i @OOLVOLAMY (p* PROPERTY DAMAGE I Wivab Ummury ANY AUTO AUTO ONLY- SAACCIDENT OTHER T"M AUTO ONLY. EACH ACCOWT AGGRE"Tj UMGRELLA FORM OTHER TKON UMBRELLA FORM 1744SA017 EACH OCCURRENCE AGGREGATE MOI ---=mm MT wourtwa ummury 1 04/18/05 4/18/06 EL FjAtw NT t 100, 000 THE PROPMETOR/ PARTWflS0MCVnW INCL OPRCERS ARE: R EXCL OTHER ELOtSEASE-POUCYUwr 1111 500 000 FL OtSLAK-&A EMPLOYE nM 01110FQEa RE: 80" AM OF INK ARIWE Pau= a c"immum " m THE 6911ROWN WE INMEM. THE "KIM MAN -1 W&L SgWanp I* rva 19— CATS"mma mm TO I'M Cmplaw HOLO M WAM TO THE LEFT ON PALM TO WJL VIAN no, mmumnD awmam OR UAINUTT I AUTHORRED RDW&OWMam C ,�o I I t David 'T. Louis j — / I�L DL 1'—z 4 IC� I i a aIS Z r�sq ce IZZ Q I Q i a LE I I� Q i a l\ OCT -17-2005 10:33 FROM:DEVINE MILLIMET BRNC 978 684 5054 4�7� 1"1 Na,lr8 BSMoOn L,Rarpr1sam Inc, NO oa mom 711 Amilho Road Andovar, MA o161a 1' Wfly A4dm _M1 Fmra StmM _ Ptm+g AnA,rvn _- nmm �4laren_ SBRTCH OF 86WACR INIM"AL SYFMM �Q 1b( x .1q r 1,H, r S% S r A A �Q Ilmar A 1e 7haN+18',9' A M I�n,a-arm" A nt"MOm�LTP a-"--SrFtleTrnk t/ 3 1, IO am S� Threr tt*ntht! 1S' h,ng TO:9786888476 P.002/002 r. nlo, UV alp r -o7 r --s n;l yz..t C7-I- scold: r �Q r -o7 r --s n;l yz..t C7-I- scold: m' o V ,`x O 0 1 vJ2 rx C '6 1 V a v k c V o C •� R � � oL C5 �0. m' o V ,`x O 0 1 vJ2 rx C '6 1 V a k c •� G 0 � � p m' o V ,`x O 0 1 vJ2 rx C '6 1 V) —!! ts m c V) —!! ts m } Y -- 'k-- `c- M w MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) . NORTH ANDOVER Mass. Date3 T /wilding Location r/W-05;; CPermit I 7L-- Owners ?/Owners Name zap r! _ New '7 Renovation Replacement Plans Submitted r] -- V\ -I= I X T 11 1z (Print or Typed % Check one: Certificate Installing Company Name�&�•�iwis� �d Corp. Address l O ,55-6 y47,llz`f' / Partner. Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter,;,,G-e A 11),6 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy✓ ether type of indemnity Q Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application ace true and accurate to the best of my knowledge and tint all plumbing work and lnttaUations performed under Permit issued fo: this application will be in compliance with all pertlneat provisions of the hdassarhuseUs State Cat Cade and chapter 142 of the General LAWS. By TYPE LICENSE: Plumber Title Gasfitter Sign Lure of Licensed City/Town- Master P1 be or Gasfitter Journeyman APPROVED (OFFICE use ONLY1 License N ber CD/--# /01-//,=, • • • • • • Y • (Print or Typed % Check one: Certificate Installing Company Name�&�•�iwis� �d Corp. Address l O ,55-6 y47,llz`f' / Partner. Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter,;,,G-e A 11),6 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy✓ ether type of indemnity Q Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application ace true and accurate to the best of my knowledge and tint all plumbing work and lnttaUations performed under Permit issued fo: this application will be in compliance with all pertlneat provisions of the hdassarhuseUs State Cat Cade and chapter 142 of the General LAWS. By TYPE LICENSE: Plumber Title Gasfitter Sign Lure of Licensed City/Town- Master P1 be or Gasfitter Journeyman APPROVED (OFFICE use ONLY1 License N ber CD/--# /01-//,=, Date. -1....-.,-1!4.:..... . "ORT" TOWN OF NORTH ANDOVER O4 t<,,io ,e ltipp PERMIT FOR GAS INSTALLATION Kj This certifies that .. y.'!lt.`.. .-.. .4.' . .... ........... . O has permission for gas installation in the buildings of .....T.>.� !....` .. ....: `'................ . at ��!�. r .� .'..... �....:...... North Andov Mass. .���; G INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File APPLICATION TO CONSTRUCT RE] BUILDING PERMIT NUMBER: TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 0 DATE ISSUED: SIGNATURE: t t`^�' Building Commissioner/Insoector of Buildings Date SECTION 1- SITE INFORMA /C;�—/3 ,Q 1.1 Property - deskr` r 6-r 1.2 Assessors Map and Parcel Number: Q � T Map Number Parcel Number 1.3 Zoning Information: 1A Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Rear Yard Required Provide Required Provided red Provided 1 1:5-0 1 4 n��J=Jfl 30 coot 1.7 Water Supply M.G.L.C.40) 1.5. Fl Zone Outside Flood Zone 0 l.$ Municipal ewerage Disposal System: On Site Disposal System RI Public ❑ Private 91 SECTION 2 - PROPERTY OWNERSHIP/ =D AGENT 2.1 Owner of Record Name Print) 4 Telephone 2.2 Owner of Record: Name Print for Service : Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable D0^1 /C© Licensed Construction Supervisor: 3 9 �J I ( License Number ss AddreO -7 O z kpiration Date Sig re Teleph a 3.2 T Not Applicable 0 / 6 Registration Number Az Expiration Ddie Ma M Z 0 z M 90 O ic r M r r ^Z Y/ 1 SECTION 4 - WORKERS COMPENSATION (M.G.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 buildigg permit. Signed affidavit Attached Yes ....... No ....... ❑ 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: 7 /4 l.7 � "'// C'='i er " d I SECTION 6 - F.STTMATRD CONSTRIWTION COCTC I 11�N' ¢ Item Estimated Cost (Dollar) to be Completed by permit applicant OFFI `USE ONLY 1. Building ' (a) Building Permit Fee t. Multiplier 2 Electrical (b) Estimated Total Cost of Construction S0� �- 3 Plumbing Building Pelhiit fee (8) X (b) 4 Mechanical HVAC 5 Fire Protection - 6 Total 1+2+3+4+5 Check Numbe . b, UIIUN /a UWf4JER AU I'HORIZAIIUN TO HE COMPLETED WHEN '< OWNERS AGENT OR CONTRA OR APPLIES FOR BUILDING PERMIT' 1,_ as Owner/Authorized Agent of subject property Hereby authorize to act My behalf, in al ers relat woZkthon"z"ed by this bIlding pen t application. -Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, V -n <"C. c- < 4_/ZA=4g -,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 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS Z 1 2 ND 3 RD SPAN CY— " DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 'F •!„ •. CzdImr, siZV, IDK�b FORM U - LOT RELEASE FORM o P� �oj/ nz INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from 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 PHONE_..-9?f Z cS % LOCATION: Assessor's Map Number PARCEL_3 SUBDIVISION LOT (S) _r STREET_ J ST. NUMBER— e�l� ************************************OFFICIAL USE I RECQMMENDATIONS OF TOWN AGENTS: RVATION ADMINISTRATOR DATE APPROVED DATE REJECTED v , COMMENTS_ I)oLK m,&sf �,L ;n same. loc4S;o,o and repl".e.J ,"n-k;�,� of no 01 ,to,al -6- was -- fwd*' re_. eW w�d be ceou,,.re-A -6,r L,,,, add.` .o.J „A,,I TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED 4 1loLJ ej wc,,,- l; cv� S.,� .Ae� PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 Jim . FEB -07-1994 16:44 FROM AMER I CAN A I Ic- IN S. LA ANI TO GALLANT P.01i01 Or- lovimSoi i I Lrr- 7 scale: 1."-- 100' PROFESSIONAL LAND SURVEYOR, DO HEREBY CERTIFY THAT THE AMERICAN SURVEYING COMPANY D ABOVE MORTGAGE INSPECTION 77 Plumford Avenue, Waltham, MA 02154 (617)893-6477 PLAN WAS PREPARED FOR l�A4fiA�t M rt . Go . IN CONNECTION WITHANEW MORTGAGE AND 13 NOT INTENDED OR REPREF N - SENTEDTO BEA LAND OR PROPERTY LINE SURVEY. NO CORNERS W1:RETHE LOCATION OF THE ..HE So1� 1b(ao on Plan 1 liww ww ��.w... COUNTY REGISTRY OF DEEDS KO'd Id101 '3!JdLos '8'd - -Kr &-t 6 'L -Z alva . '71 A8 03NO3Ho 03.Ld d0 03013W # 19NVd � �ILINnINWOO � � .'3 ,� a31Va dVW 3LdH 3pNVHQSNI 0001d WVHC30Hd 3oNVdnSNi QOOid 1VNOLLVN NO NMONS SV 3NOZ OOOld NI San ONM3MQ 1p3mnS 03.LV0rat: # i3OUVd —Z3 d7— S,HOSS3SSV , d0 NMCLL Had •s3Nn HoV813S DNINOZ 03aInO3H NO AIU3dOVd WOHd S931 NO .t 38 Ol NMOHS BBV QUAlOnH1S N3HM 03SIACY SI A3AdnS LN3WnU.LSNI AVO1VWHld •NOO V 'NO3H3H NMORS NO 0310N 391M1 M10 SS3•INn 't 'pas 'vote • KWHA311LL-M'SSMUSONnNOLL -OV IMM30HOAM NOI1Vl01A WONA 1dWM SI MO'(AlNO S1N MinD3H 1VNOISN3W10 IV1NOZIHOH 01103dS -3H Hum 03LonH1SNOO N3HM load -0 NI sMvuS ONINOZ 318VOnddV "VWM'l x411 U I IM ar1NNiZ.IWA!1 IUI QWAA off--N•ar _._.q-t-rz r•;13a lNano 1'IFl�" J.N3110 030H003b Be 01 030NH1.NI .m St 11 'iNVdn000 mo H3NMOOM ERLOlNI3d3H030N31 -X9 SI AA11SISNOdS3H DR 'AVM dOSlJ401W ONVSIN3W3SV3'SONIXV.L 'S3ivs-ln0 H3H1Hnd Ol losrans 38 AVW 0NV NOUVWHOdNI 03HSIN •Hnd 1NMO NO a3SV8 SI NO3H314 NMOHS SV 0NVl3Hl'S3Nn 9Nt(nin8 NO 3003H '36N3d nNIHSVISVi The Commonwealth of Massachusetts_ Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: 1) ori A -c_ t,> 1C 61-L- c7 wy4--/ Location: Z (_2 M-4AJI-SO n) City ��'y C-m� Phone # T ?P 97S 2 3 7 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity Ee�I am an employer providing workers' compensation for my employees working on this job. Company name= 1>Q&Ak-r7-- Address Zo �rr41.LJ i.s0 •j City S,;t OLJ Phone #: Company name• �Z�4,4c b Zl� w Address City AJ>F'af'AW Phone#: pnlir_v * Cl�s�O 1 /% 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_ciAl,penaftiesin-theinrm d -a STOP WORK ORDER and -a fine dl.$1-00.DD)-a Aayagainsime. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do hereby certify Signature. of perjury that the information provided above is true and correct. Print name Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept []check if immediate response is required Licensing Board p Selectman's Office Contact person: Phone A- Health Department Other X Fa W0 Q a _ Y 1 ` 11.0 0 �yy (J] X ti W Q O_ N N V1 a Vcf G (n W LU Z 3 p 0 z Z LL ❑ °° a 0 J W N D F'LL Ix 0 0 H O Z W w N w Oa 0 m D NL a z m J_ C9 0 CH Im W CL eY 0 Z H Z V F- a l0 Z 0 N N N W � f ❑ Z a o z a 0 0 N N a W Q w W F ? NN 0 0 0 en a I� W m f 0 0 J LL LL bmw4m l %I ''j N J m LL 0 z 0 z ❑ N n0 N Z 0 ¢ ❑ Z z Z LL 0 LL LL 2 0 S N } w Z F 0 W 0 J a i J a ti � r -U Z 1 i D x 0 m z w a N N z Q i a W ¢ z 0 z o 0 LL LL w Z 0 } m m ? tt LL 1 • N 0 m L z ` N v N w a N z > 0 � z N a. 0 U) U U O J � w � W N N H W W a: J F (7 0 m t7 ❑ m 0 w H 0 Q w W N J 3 ❑ Z Z i W ❑ z a m z 0 m M o z -- N J O ❑ f W z z z O J J N } z LL z 0 r U a N J ¢ W a a a LL 0 O a' ¢ 0 m U1 z J a a O r -U Z i D x 0 m z w a N N z Q i Q ro a a 0 z o 0 LL LL 0 } m m ? 1 • N 0 m j N i z W N a N a N z > 0 a. 0 U) U U U w a N N (L a 00 O t7 m (7 0 m t7 ❑ m w IL V Q W ❑ 0 0 M z J F W F W F: W a N d J F- LL U1 z 0 i D i � N Z j � M ( N j N i z z I 0 O O O w w N N > W ❑ 0 0 N J J F- LL 4 0 0 N m w W j w 0 0 w a a N a a i F - z I w 0 i a ❑ I N 0 x ) � a It 0 1 I z 0 LL0 ❑ W LLJ w \ a W J z 0 ❑ N 4. . 4 I I MIIIIIII K R U2 ZU& Cr o� 4 ✓ia�Z Q I-J 0 IL j0E- LL o 0oa N Z=N 0mU W0a S Z ON H UNI l< Z lT k WI0 -, tC LQ 0�0�► - Ffa. U �F NWW � 2Z"a zQN ONF- Z - Uww U O W N J w N N F0< } U Z 4 r .S P'n � �IIIII I I MIIIIIII I I IIIIIIII TIC.;§ Z O O Z m w�"�. aZ r ¢ O LL C LL a ¢ > Z Q¢ LL 3 �w YU��V , za .0- Z z 0 r' 2 0 w_ N �,., d LL w O v zz3LL v> m � 0 O o' OF�� o ¢ O ww F 3� 5 f f w o �o� o¢ ow3"�o¢ No .' �zZ= ou < ua r LL U N Z m, v o'= V w x a x a o W o w 3 ¢ r u M OO auj ta} � OG=u< Q Do ^ ¢O¢a'=0Q0�� °.Or-o25<z<''�O LL w .n¢ m�3�xzw� a v�x¢cDU' OwZ I I1TI I I I I 1 — II I I I Z I— .I 0 h U c O ' t- W wC�Z z o } z > m� z LL v¢i zo a¢ x�v,ON w Z f vi Our O O O J YZ W Q 3 C�z�U' ¢¢O�o�� �wQ¢ZQLL O rc z� -'Z m LL ad Nth — �� ¢¢Z N O LL m0 yr m pZZ�vrzZZi�v� �xz >,i Z ~O � J0 zn 000000 Jv� 0O O mks ll-� m wm� ma0wOOvOZZZ N mfr-=0r=� O mw0N 6 a��= X03«>��mmuoo (D(LL<3N�� to 3 �3 n m� 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: (Location of Facility) Sig ure of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector xl� ~o M 0(.� L IAS 1 Fil �. A O x 0 w T a. chi o � z z "a ° .o o w -� o cG � U c w" U U w a � o w c w" 0 W U w w � ao' � c� _ `° w o � Cf) ►- � °�°0 —c" w w w w v cn z cn o v V) O z o a Q :1�) 47 vQ0 v/ �O• N E C V c `NG �P c o C it O N C O O :vv 71 a C W R CD C SS S� .`• O � O z o a Q :1�) 47 vQ0 v/ �O• N E C V c `NG �P V m c E • N W z to N C13 N m0 c • O . � Eco m �� _ Qac O mm y 10 . �; • Z � O Q1 O: cc. -), y O 0 w D7 Q 0 m C •p = m : t m_.. 0 N �O. r0. N m co t W C = w L umi C .0 F. •N d t Cc. C Z Cc =� m�N O v m om�c g Vo a m O = oCL •`—' '� $ 0, CO 0 V / W P 101, 0 O D Cn LLJ C) W W W U) Town of North Andover Office of the Building Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Date: To: Address: From: D. Robert Nicetta, Building Commissioner Re: PERMIT PICK UP Telephone (978) 688-9545 Fax (978) 688-9542 We have attempted to contact you with regard to your Permit #�a/ . This Permit has been ready for pick-up since /a 43'�' If you do not come into this Office to pick up and pay the fee, an inspection will be conducted and appropriate action taken if we find that construction has begun or has been completed. BOARD OF APPEALS 688-9541 BtIILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 l - Al �_� 0 0 EMO w v w cin w co w° a°G ° U w PQ ° a a � a w°�° c°G cn w o a d w°' cuo ii A w v z cn v cn cc o' cj CS m :z o i 1t .1 Qu W TI�N J o : E C f' `NG �Q' V cc .a S ZIL Z cm z c�my H : >� cm:m c ' Vy O C O C, •E OA L- CD OI y' r -COD C O�; O c0 m : C7oj h O Ocm H We �. N co O. c •c Lju ~ w N m y0+ ~ m COD C W Z O r=.+ NJ =:s .� � A •go d t c Z LU � cS = o •y O CIO CL om c gGo go cmCL:a Co co O co O V CD CL COD o c � c cm CD CM m i O O CL ~ 3� a� CD 0 0 cc 0 CL CMQ CO) •C 'C O C CO3 2E o � C CD CL U CO) C �C C _c QCOD _0 Cn LLJ Ir w W 'ajnj3n4s u. naoo 01 iou peum 8J Aouedn000;o epog4jeO (ApeaH 98) 00'SZ$ - ael uoipadsui-alj •uo!padsui jol paimbai sjiels Ajejodwal •ainlonils 6uiAdn000 of joud pannba.i Aouedn000 jo aleogpaO •aloldwoo 6ulpej6 joualx3 -mels jellao uado ap!s6uole paiinbai sllejpjenO ;sod llemau/Ilem of pawnlaa sl!eJpueH :HSINId aseq eels le ped •ouoO 'ngy umop s6upol Jaid •spej pue slsod lie Bel •6uloejq lejalel/m s;sod gxg asn 'apej6 anoge ,g JOAO aalueo uo „g aoeds xew jalsnle8 '4614 n 9£ -u!w sl!ea •6uigseg ap!nwd 'asnoq of Bel :pajinbei l!wad alejedaS :SXO3a -pns •lsngwoo @ p!los ng `slulof uealo '6U16Jed yloows ys!u!d - aagwe4O allowS - 6wlood le suo!loadsul •pannbei l!wjad alejedaS :S3O`dld3Hld 96ejols jol pasn l! mels japun apooeii j -duan 96pu pannbei pue jWos 'Wluan jadwd, - sooeds oi:p luOA •poop Jo mopu!m ssaAa t�ZxOZ •u!w paj!nbai swowpa8 •algeuedo aq Heys 6u!zel6 pannbaj to y -ease joog to %9 of lenba 1461i IeinleN :aneH lsnlN woo8 elgel!geH tiaA3 jo ainpapS mopuiM sanols 19 saoeldanl aouejeolo Q0. to awed poom a/S apooaald '(lWos u1 lou) aoualxa of lonp lelaw aney of sue; lsnegxa yle8 Inx9i, •u!w) •ss000e aoeds lmejo •(anoge wowpee4 ,£/m O£xZZ u1w) •ssaooy ollly sweaq japun 'sAemnels - seoueaeolo wowpeaq 1384O -Ole swea8/sJape9H jol lioddns 6uueaq p!IoS -sessnjl s,lAl/swea8 jol pannbei •suoilelnoleo pag!1,aO •spue le 6u!oejq Ieaalel •slallood uo!lepunol ui saps le coeds i!e � �, suoilepunol le 6uueaq aleld laals jo Nouq p!los - slnO 'leas Ills/m (ldl) 9XZ-Z saleld II!S •sl!eu ia6ueq /m pepeu Allnl - sja6ueq ls!or •lioddns leay pue slno golem - sj96uuls i!els aleld of ail usd!1O eueownH. asn pue suogoauuoo jadwd ap!nwd sjal}ei low ieipayleO •suo!loauuoo jadwd ap!Awd - d!H �g 96p!a •sllem le 6wjeaq golem - siallei AelleA pue d!H •slno jo4ei le 6wjeaq lint ap!Awd of 96pu oz!S •suollped 6uueaq jaluao pue sjauaoo aoejgpu!M -sra6uuls gels le slleM •ola 'oolo 'leaq '6u!gwnld jol suo!leJlauad ls!of joog uaengoq saleld/spB JOAO - Noolgand :31Nb'ad wipauuoo lallno pue janoopalig ougel/auols/adld - u!ejp uo!lepuno j 6ugowdwea sdeils jo slloq jogouy pannbai se jegaa :NOIl`daNno=i suwnloo joualui jol s6ullool dials snonulluoO AemAe)i tixZ Ilnd snonupoO :SJNIlOOd Ieu!d 'uo!le!nsul 'awejd 'uollepunod '6ullood ' uo!leneox3 (wnw!u!w) :SNO11O3dSNl suoipedsui ou Jo'•(XO AdOO) liM13d (INV 'SSMI(MV 'M38Wf1N IOl 11`d ISOd MO138 SW311 01 (MIN11 ION -ISll)lO3H0/S31ON 0NIQ11f1s lV83N3J a ` 0 45426m 4 rn R, n 49p 8 tl S •391 {9 k4 0 i R 12AC 75.2�y U 8 93,730 •? _ y 94089 �D o N " V C CR rl CD COY)o N k. �. 1.05AC cp N V $ V O IAC JI♦ /i n ti V Q r Yn .. j A O 7 _I Y• j _ � O (VO R i,N� oN 5 n w1 sa G (Wn c PLACE ROAD N is N co O n1 N g 88 :'j y 6H8•ft V •$ • Np I� $ pj rn aa U uS q x �i `bit m S it b T' p A N iEB CY N g �i Y u N / N U 1r N N • Ol Y m h N� N. �O p N Y =1 (O Tin ..`H 1 3"e �j -� 2 -mac i N ,9C G N y `o 2f V 4 u N _ t4 V C1 N O �fic,� ' O 2.00 - n ' u N = pp ) r N O a w NV\ N ~ d C7 •',I � JI %t N NO • -+ V � f� b r - � Y •Q N t N A y O p__a fD 7 �� Ft` th 3'C 9 L VCD N 0. � � j Date. . *Ml# ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Q This certifies that - has permission for gas installation:�G- !`!�ha�.... . in toe buildings of ........... ..�.. at ......... North Andover, Mass. Fees!-....... Lic. No.. .......................... Check 4 �hL GAS INSPECTOR 4886 MASSACHUSM TS'UINIFORM APPUOATiON� V -nm a type).. Na" Ny6R. Mass. 030 /0 i G iVWPERMIT TO DO GASFrMNG- New ❑ Renovation: -❑ pRo Pians. Submitted. Yeso No°p InsWhg Company Nwm= Ac � Address_ 5 N Business Teleohone -75i r - -c s.d - �.., Name of Ucensed Plumber or Gas. Fitter ❑ Partnership A Firm/Co. INSURANCE: COVERAGE:. I have s%_ iv W lit *w ar�oe�pdky oc Its s titfegt*Ww*-which-meets Nw-requiremerrts o(_�MM-SCh. -142• s No 13 If you have:ebedasd Tessa e3ype ov+e age bj► checking the appoopdate;box, A IW3#ity insuranoe_pdky)( Othectypeockdemrity.❑- Bond- ❑ OWNER'S INSURANCE WArVER: I am-awwe that.the licensee does-inot_have- the hnsuanc a coverage required=by, Chapter. 142 'of the Mass,General- Laws. _and ahat.my sign h re -on Vds•permit-application waives this requirement Check one: Signature of-OwneriW-�Owrwrs Ag6&. OwnerO Agent,❑ I hereby cw* that an of the details and information t hake submitted (or entered) inabave application are true and aecurate.to.the best of my knorrAed9e and brat aaH plurtrbinp wo* and instaktionspedwmed under the permit issued this application will be in compliance with all Pertinent provisions of the Massachusetts State Gas. Cods and Chapter 142 of the General - T of ucense. True _ Plumber nature of u or er casfitter - City3Town Master License Number 131aLo. � o _ o d z d Yl Z Q W O O / � W •4 O _ � J d Q W W !V r ' ir � o o z d C Q O' O O � W O V J d IL W W !V ' W - w x V w ' Y a Loi Oe HORTM ,� -• o O 9 Date../ G� TOWN OF NORTH ANDOVER - PERMIT FOR PLUMBING SSACMU`>� �%f rJ J 611 97- This certifies that-... . I . . . . . .. has permission to perform plumbing in tube bul duigs of ✓...... at .7` .�%i ............ North Andover, Mass. Fee))' f / PLUMBING INSPECTOR Check # /j(y� . 6211 MASSACHUSETTS UNIFORM APPLICATION F�Ofi PERMIT TO DO PLUMBING or T ) Mass. Date Ad 1 o Permit ,d�//-/.12" Building Location ZLLrowners Name . / RC14 Type of Occzjpancy (T -L IN New 0 Harz W7,14 ,1:i Plaza SubmitteCt Yes C� No G Check am O Corporation C3, ,K FMVCM Name of Licensed Plumber INSURANCE_COVERAM 1 Nave a ctnrent liabilo icy or its sul76tantial equivalent which n mats the n�uirernents of MGL Ch.142 Yes ff you have checked yes, Please indicate the type coverage by checking the approprMe boot. A liability insurance policy -g Other type of indemnity p Hoed OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage rewired by ChaMer 142 Of the Mass, General Laws, and that my sib on this permit application waives this requirenwft Check one: Sign ahm of Owner or Owners Agent Owner Agent G I hereby certify that all of the details avid mfornaban I have submitted fa enter" in above aPP&Mion are true and a=urate to the gest of my knowledge and that all plumbing wcx and iru=lahom performs under the be in with ap pertinent Orasion5 of the t+eassache0 fathis application will s, a,W Ct 'er 142 of the General Laws, at Type of License MMKX Jcumernan L License Number Y V - • • A S • 1MENINEEMENEPINEEN *A *! NEEMEMEN Check am O Corporation C3, ,K FMVCM Name of Licensed Plumber INSURANCE_COVERAM 1 Nave a ctnrent liabilo icy or its sul76tantial equivalent which n mats the n�uirernents of MGL Ch.142 Yes ff you have checked yes, Please indicate the type coverage by checking the approprMe boot. A liability insurance policy -g Other type of indemnity p Hoed OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage rewired by ChaMer 142 Of the Mass, General Laws, and that my sib on this permit application waives this requirenwft Check one: Sign ahm of Owner or Owners Agent Owner Agent G I hereby certify that all of the details avid mfornaban I have submitted fa enter" in above aPP&Mion are true and a=urate to the gest of my knowledge and that all plumbing wcx and iru=lahom performs under the be in with ap pertinent Orasion5 of the t+eassache0 fathis application will s, a,W Ct 'er 142 of the General Laws, at Type of License MMKX Jcumernan L License Number z ro z ' 0 0 z a - a A its 2 2 G Z 30 r O A m ro z z z mc v IE i _ r LE o O c Z O � C �h %.ummunweann Or Massachusetts t tl)ici,tl (:,c t fill - -, Department of Fire Services 1I>et,ttit;°, �-� Occupanc\ and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1051 ,ICatu blank) C, APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK .11] .)irk to hr pertnrmCd in accop.lance ttith the \las;;ichusutts I':lccU•ic,tl COLIC (\IFC). 5i" C\IR 1-1.01) 1PLLISE PRL\fl.WWORTYPE .I Ll.�•FO IfITIO) Date: City or Town of: 4,1j, e r To 117e hININ'c'101' 0/ 11"h .S. 13y this ;tpplic;ttion the undersigned kms notice (it, his or Itcr intention h) perti>rttt the electrical Mirk described below. Location (Street &Number) ,Zq 7 (honer or Tenant jr��dTelephone No. Owner's Address 2q'7 4i fe-.4 Is this permit in conjunction with a building permit? Purpose of Building Existing Service - /00 ;%nips / Volts New Service 900 Amps / Volts Number of Feeders and Ampacity Location and ,Nature of Proposed Electrical Work: Yes ❑ No [R* (Check appropriate Box) Utility authorization .No. Overhead Undgrd ❑ No. of Meters Overhead Undgrd ❑ No. of Meters 1 .1/lr;ril -1r•LI11 ;j,/r T';'c'i 1, •;,',ec,'l'. Il,I'c' Fr:timated V' iluc of El vri ;d OV k: 1 1 �•� bun rcyuirCJ by nnmicipal p(,,licy,) Lurk to Mart: s Inspections to be requested in accordance L�it.h MEC Rule 10, and upon CuntPICtior). I,NSLRANCE C )VE M..'E: l nless tvaivcd by the otvnur. no permit for the performance 0fcle0'ical trork may i aue unlC', the licunsee prop ides proof of liability insurance includim, "COMPletcd ,tperation • coverage or its >.t.tb,lantial Cqui�alcnt. '1,I ,nder:,i, ncd ccrritiC: that -,nch in I,(>rcc.:rttd has c•.hibited prnnt i:t,:at;te to the permit II:a:!< E);'�I�: R�`;I. !Z,\�.t,'I:: ❑ 13t;�.1) �� �; fFll•.R the;1ll:ll.v.,rJllll)4.'714711%r'.,?1 peY/Clia', ?IUr.'/lt';/1�0/''!1/t/.CO/1 ,;11 J11J' r!!7/rCc!/AlrYl !.);1'rrC''1.'l� l'I7 •'/7/,..'/�'. �� s R,bl NA.yI lE: '.,seensee: �t,/C• � � �_._--•' � i -- - �--_-- "-..74.'..`.x).:.__..------... n t ;at;,t;lrc l ii..' ;Chi.rel• ...•cl/ rli .i„• l,. 1.: • ..,,nli, ,.,1�. --- .- --- "-!._. Address: _ --- rp Sus. 3'el. ''o, y �� -- ;ecurit v.,tuln C„nn'actor LieCnSC R:L meed I' A this v ork; i�It. )fel. y V I �l•;iC.,' c', Cntcr the license nurnber t)WNIER'S INSI RA.NCE 'WAIVER: I ;int awtrc th;tt 111, Li:cn:ec,.lr;,, nr,l hllr,.' the li:.tbility in:;urnnc'. •:•)' :;n'.0 n rtr.;,ll;. is:µtired by law. By my -:,,nature bclotr, I tvaiaC this; rCqui1—(Jl%nt. I Owner/Agent t the (check nnC) ❑ .;ttner ❑ otencr':, .e,:nt. ('„nr :hNiun rr/'ll,r /r,lhnr ilrs> luhle rout I>e trtul. cl by !hr lr,.i ;t'.Yil• rl/ I1`; No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans NO °f Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires Swimming Pool .% ove ❑ In- ❑ o. o mergency Lighting �rnd. grad. Battery l'aitsLL� No. of Receptacle Outlets - No. of Oil Burners11711RE O ALAR, S �No: efZones No, of Switches No. of Gas Burners No• of Detection and L Initiating Devices No. of Ranges No. of Air Cond. Tot sl;, No. of alerting Devices Heat Pump Number Tons KW IiNo. of Self-Containe Totals: ......_... _.. .... .................._ . No. of Waste Disposers Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ �luntctpa ❑ Other No. of Dryers L =- Connection Heating Appliances KW Security S ~terns:* No. Devices 0 of Water Heaters KW of or Equivalent Vo• o f No. o Data Wiring: _ _ Signs Ballasts No. of Devices or Equivalent_ No. Hydromassage Bathtu`lbs No, of:Nlotors Tntal HPfelecommunications Wiring: - OTHER: No. of Deviecs or Equivalent .1/lr;ril -1r•LI11 ;j,/r T';'c'i 1, •;,',ec,'l'. Il,I'c' Fr:timated V' iluc of El vri ;d OV k: 1 1 �•� bun rcyuirCJ by nnmicipal p(,,licy,) Lurk to Mart: s Inspections to be requested in accordance L�it.h MEC Rule 10, and upon CuntPICtior). I,NSLRANCE C )VE M..'E: l nless tvaivcd by the otvnur. no permit for the performance 0fcle0'ical trork may i aue unlC', the licunsee prop ides proof of liability insurance includim, "COMPletcd ,tperation • coverage or its >.t.tb,lantial Cqui�alcnt. '1,I ,nder:,i, ncd ccrritiC: that -,nch in I,(>rcc.:rttd has c•.hibited prnnt i:t,:at;te to the permit II:a:!< E);'�I�: R�`;I. !Z,\�.t,'I:: ❑ 13t;�.1) �� �; fFll•.R the;1ll:ll.v.,rJllll)4.'714711%r'.,?1 peY/Clia', ?IUr.'/lt';/1�0/''!1/t/.CO/1 ,;11 J11J' r!!7/rCc!/AlrYl !.);1'rrC''1.'l� l'I7 •'/7/,..'/�'. �� s R,bl NA.yI lE: '.,seensee: �t,/C• � � �_._--•' � i -- - �--_-- "-..74.'..`.x).:.__..------... n t ;at;,t;lrc l ii..' ;Chi.rel• ...•cl/ rli .i„• l,. 1.: • ..,,nli, ,.,1�. --- .- --- "-!._. Address: _ --- rp Sus. 3'el. ''o, y �� -- ;ecurit v.,tuln C„nn'actor LieCnSC R:L meed I' A this v ork; i�It. )fel. y V I �l•;iC.,' c', Cntcr the license nurnber t)WNIER'S INSI RA.NCE 'WAIVER: I ;int awtrc th;tt 111, Li:cn:ec,.lr;,, nr,l hllr,.' the li:.tbility in:;urnnc'. •:•)' :;n'.0 n rtr.;,ll;. is:µtired by law. By my -:,,nature bclotr, I tvaiaC this; rCqui1—(Jl%nt. I Owner/Agent t the (check nnC) ❑ .;ttner ❑ otencr':, .e,:nt.