HomeMy WebLinkAboutMiscellaneous - 3 JOHNSON STREET 4/30/2018rl)
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. L I-- -- 7 -le
................................................
has permission to perform ................... ......... .. .. ..
...............
wiring in the building of .... ...... 4n4kT
at ..... ........ 52. . . ............... ;'Iq?rth Amdover, Mass.
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Fee.. �Z No. 4 ............
Check# LEr4r.R I NSPECTOR 77
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use
Permit No. q, 0 S- a
Occupancy and Fee Checked
tev. 1/071 ki..LN
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (M EQ, 527 CM R 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date: /-, - � �?
City or Town of: NORTH ANDOVER To the —Inspe-ctor of Wires.�
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
-- /,V, /�� t(, 7 - A4,141,4- _
Yes Ll" No n (Check Appropriate Box)
Utility Authorization No.
Overhead Undgrd F-1 No. of Meters
Overhead UndgrdF] No. of Meters
C0.,.r,Ji—f,h I/- ; I./ -
No. of Recessed Luminaires
R
No. of Cefl.-Susp. (Paddle) Fans
Ina ve walved by theinspector of Wires.
No. of Total
Transformers KVA
No. of Lundnaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Atiow—err-1 In-
-
No. of Emergencyl]-i-g-liting
_�I�rnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARM f Zones
No. of Switches
No. of Gas Burners
No. of Dete tion and
Initiatine Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
No. of S-elf--Co-ntained
JKW1
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local (I Nl-unicWl El Other
Connection
No. of Dryers
Heating Appliances KW
S
-go-7of Water—
No. of No.
or Equivalent
Heaters KW
of
Signs Ballasts
Data Wiring:
-Telecommunications
No. of Devices or Equivalent
No. Hydromassage Bathtubs Total HP Wiring:
No. of Devices or Equivalent
OTHER:
,4ttach additional detail ifdesired, or as required by the r of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start:-/� - /, - 0 f Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE tOVERA-GE: 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 it-, substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ' ONDE] OTHERE] (Specify:)
Icertify, under thepains andpenaltiesofperjury, thatthe information on thisapplication is true and complete.
FIRM NAME: P. f
Licensee: (or oor Signature LIC. NO.: 915;, 7.3
J'm ' �/l LIC. NO.:
(If ql,�plicabh. -,n r-'V�empt - iZhe �Iicense number line.)
Address: R.8%. I?ef ko.: 4P- 7, - z z
*Per M.G1 c,'147, s. 57 A It. Tel. No.:
's
-6 1, security work requires Departm. of Public'Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does no-i'llave the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) C3 owner
Owner/Agent _ [I owner,,; agent.
Signature Telephone No. LPE�M::1:T FEE. $
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .......... ....... .... /51111
has permission to perform .... -:7 ....... ...... ..........
wiring in the building of ..... ............. ....................
at . .............. 4;� .......... orth Andover, Mass.
Fee ... No.
.................. . .. ....
Check # ELECMcAL ImpEcToRV
9 Y/ 06
7 4 46
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SAr.0
Date. /�/w 00 .....
TOWN OF NORTH ANDOVER
.PERMIT FOR GAS INSTALLATION
This certifies that ........ ......
has permission for gas installation ...... . 4 I'VI"Ad ......
in the buildings of .... �� r. C-11 ..... . 5
a t 3. .—'4 ..... North Andover, Mass.
F`ee,31.,.Q0 )Lic. No. .7,.nv .. ... A# ... ..
Check # 8-7o4 GASINSPECTOR
MASSACHUSETTSUNIFORMAPPUCAT)ONF)ORPERNUrTDDO GAS FTrnNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date / C, // r-11 0
-3 j 1V7afJ1J
Building Locations Permit
41C4< 5�b/Le '49-67�yry Owner'sName ,,,mount o o
New Renovation Replacement ER Plans Submitted
(Print or type) Check one: Certificate Installing Company
Name NP46XI-) Z Corp. 9- q,7 6
Address If-lb'41yL,116"I #y4r- nJAI� 4)1-,0rw FlPartner.
Business Telephone Firm/Co
Name of Licensed Plumber or Gas Fitter lyleA44-e-L
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes FLI No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 10 Other type of indemnity 1:1 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.
I Check one:
Signature of Owner or Owner's Agent Owner El Agent 1:1
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 Linder Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State �as Coje and Chapter 142 of the General Laws.
lCity/Town
1APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber �7 Y C-4)
Gas Fitter License Number
Master
Journeyman
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(Print or type) Check one: Certificate Installing Company
Name NP46XI-) Z Corp. 9- q,7 6
Address If-lb'41yL,116"I #y4r- nJAI� 4)1-,0rw FlPartner.
Business Telephone Firm/Co
Name of Licensed Plumber or Gas Fitter lyleA44-e-L
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes FLI No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 10 Other type of indemnity 1:1 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.
I Check one:
Signature of Owner or Owner's Agent Owner El Agent 1:1
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 Linder Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State �as Coje and Chapter 142 of the General Laws.
lCity/Town
1APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber �7 Y C-4)
Gas Fitter License Number
Master
Journeyman
Oct. 18,
2010 12:OOPM
No, 5246
P. 1
Aj!�C?ftb'
CERTIFICATE OF LIABILITY INSURANCE
cp,D ,,
MODER-5
—
r DATE (&700"
1 10/18/10
PRODUCER
--fH-13 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
TD Insurance, Inc. (NA)
One Griffin Brook Dr Ste 100
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Methuen MA 01$44-1865
NSR1
TYPE OF NSURUCIR
Phanes!1178-688-4667 Fax;978-682-9037
INSURERSAFFORDING COVERAGE
NAIC
INSURED
1146LIFIERA: HMOVER INSMWCE C.O.
22292
modern Mechanical
Cgntractors,.Inc,
Michoel CV 014
18 Rivervz:w Avenue
Methue
1143URER 9; Egnaver AMOV1.44M laDgIrwo
36064
EACH OCCURRENCE $1000000
[INSURERM
__ — I ___ -
�wvnm��=Q
THIS Poxiis OF INSURANCS LISTED BELOW HAVE BEEN ISSUIED TO ThIt IN6U%D NA.MED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY RIQUIRMNIT, TERM OR CONCITION OF ANYCONYRACT OR OTHER DOCUMENT WIT61 RESPECT 70 WHICH THIS CERTIFICATE MAY 663SIVED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED ARRIIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITION$ OF $UCH
PM063. AGGRIOATIE LIMITS $MOWN MAY HAVE &&IN REDUCED BY PAID CLAIMS.
LTR
NSR1
TYPE OF NSURUCIR
POLICY NUMBER
*0 Owl
LIMITS
GENERAL LIABILITY
71 COMM9R0A4OjN%RAL0A1ILITY
EACH OCCURRENCE $1000000
$100000
REN7572447
03/01/10
03/01/11
CLAIMS MADE FK7 OCCUR
�EDEXP(MyOftqcpon)
PERSONAL & ADV INJURY 11000000
GENS1%AL AGGREGATE $2000000
GERL AGGREGATE LIMIT APPLIES PER;
PRODUCTS - OOMPIOP AW $2000000
POLICY 17-' 'EREj
I j LOC
IWTOM02166
LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO
(b wid6m)
ALL w4NIip Auros
SCHEDULED AUTOS
1100116Y INJURY
(Per pamon)
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY
(Per awdent)
PRC"RTY DAMAGE
GARAGELABIUTY
AUTO ONLY - EA ACCIDENT s
ANY AUTO
OyHSA THAN _FAACC '$
AUTO ONLY; AGG $
EKCESG� UMBRELLA 41ASIWTY
FACHOCCLIRRIENCE 6 1000000
A
7x=VR DCLAIMSMADV
UIW600484
03/01/10
03/01/11
AGGREGATE $1000000
-7
woucnem
X I RETENTION $10000
$
AND EMPLOYER LIABILITY Y/N MY WMhCT
B ANY PROPRWORMARTNEPAXIOUTIVt] WZK7359897 03/01/10 03/01/11 E.L. EACH ACC109NT
O"CERNIMBIR FXC4UDED? 1100000
(Morlostory in 4H)
wdlotwt* willer E.L. DISEASE CA EMPLOYEE $100000
AL PROVIBIONS below E L. DISEASE POLICY LIMIT 10 5 0 0 0 0 0
OTHER
DESCRIPTION OFOPERATICNIS I LOCATIONS I VEKICLES/ FI(CLUSIONII ADDED NY 9NDQR3 INIT I SPECIAL PRbVLISIQNS
PlUnbinq; Comercial
"V6WCM cAijein I wrinu
Town of North Andover
Attn; gas Inspector
1600 Oagood ot
North Andover KA 01845
25 (2009101)
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED 61FORE 7HE EXPIRATION
VAT9THIER9OF,TMF ISSUING INSURER MLL ENDEAVOR TO MAIL 10 DAYS MTTjN
NOTIC TO TIOIE CERTIFICATE KOLDIR NAMED TO THE LEFT, BUT FAILURE TO 00 SO $HALL
IMPOS: NO OISLIGATION OF. L LABILITY Q F ANY KIND UPON TK9 INSURER, ITS AGENTS OR
R11PREGINTNrim.
1)
FrIf AGUIRD name and logo are registered marics of ACORD
reserved.
ct, 18, 20,10-12:01PM 5248 P,
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the pAicy(ies) must be endorsed, A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsemen�s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsoment(s).
DISCLAIMER
This Certificate of Insurance does not constitute a contract betweer the issuing Insurer(s), authorized
representative or producer, and the certificate holder, nor does it affirmatively or negatively amerid,
extend or alter the coverage afforded by the policies listed thereon.
25 (2009101)
.&I
COMMOnweRlft Of Massachusetts Uttletal Use Only
Department of Fire Services PermitNo- 13,71-
Occt4mmy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS v- 1/071 11... kj_j,
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All w01k to be Performed in accordance with the Massachusetts Electrical Code (M EQ, 527 CM R 12.00
(PLEASE PPJNT IN INK OR TYPE ALL INFOMA TION) Date: -�—, '? ,,- &
City or Town of'. NORTH ANDOVER TO the Inspector of Wires:
By this application the undersigned gives notic; R-71ii; �r her intention to Perform the electrical w2lk described bejpw.
Location (Street & Number) _.;?, -,� 0, _r6el- ') ez- 77e OL,- n
Owneror Tenant A7 .41
Owner's Address
.Ir� �A- 7 t.
Is this permit in conjunction with a building permit? Yes E-:
Purpose of Building 4 -r
-d 'a / -
Telephdnj So.
No El (Check Appropriate Boy,)
Utility Authorization No.
r,mstmg 3ervice _4c-,
:, Amps QALLjj�&Olts Overhead Undgrd Q---- No. of Meters
New Senrice Amps I volts ()Verhe&dE] UndgrdE] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed
Electrical Work:
Of I
No. Of Recessed Luminaires No. Of CeiL-Susp. (Paddle-) Fans
No. of Luminaire outlets
No. of Hot Tubs
No. ofLuminaires J Swimming Pool X957ve�n
U
No. of Receptacle Outlets No. of 01, Burners
No. of Switches No. of Gas Burners
e
No. of Ranges
No. of Waste Disposers
No. Of Dishwashers
No. of Dryers
A No. of
Heaters
No- Hydromassoge Bathtubs
OTHER:
No. Of Air Cond.
A�
ALARMS
Inspectol
Total-
-KVA
KVA
111fig
of Zones
of Alerting Devices
Estimated Value of Electrical Work: a stavoT aaasuonat aetail �fdesired, or as
Work to Start: (When required by municipal policy.) rcquired bY the Inspector of Wirej
I N S U R A N C If -C-0—V E R A �GE - Inspections to be requested in accordance with MEC Rule 10, and u n mpl io
. Unless waived by the 0 PO co et n.
the licensee Provides proof of liability insurance i judinnne-r-c'Ono Permit for the Performance Of electrical work may issue unless
nc mp eted Operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the Permit issuing office.
5�
CHECK ONE: INSURANCE 04'16ND [3 OTHER [I (Specify:)
I cer105?, under the pains and penalties ofperjury,
FIRM NAME: that the 'nform"Off on this aPPlicaden is &ue and complete
Licensee: LIC. NO.: A915PI.T-5
Signature
(1j'appolivable. en
ex�empt �in the lice�nse number line.) NO.:_A 7 11
Address: Bus. yefcclo.-ZZ
-,0, 'd I!U-i
Alt. Tel. No.:
4 Dipattmajji��
*Per M.G. L c. 147,,q. 5 -6 1, security wci! li� V luire. 9=
'i 111'Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ol have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE.- $
6 Detection/Alt
SPaWArea Heating KW
Low i"IT-1
C Com
Heating Appliances KW El
Sec u S,
No. of 1110.01
Signs Ballasts
No.. of
Data Wiring:
No. of Dei
No. of Motors Total HP
Estimated Value of Electrical Work: a stavoT aaasuonat aetail �fdesired, or as
Work to Start: (When required by municipal policy.) rcquired bY the Inspector of Wirej
I N S U R A N C If -C-0—V E R A �GE - Inspections to be requested in accordance with MEC Rule 10, and u n mpl io
. Unless waived by the 0 PO co et n.
the licensee Provides proof of liability insurance i judinnne-r-c'Ono Permit for the Performance Of electrical work may issue unless
nc mp eted Operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the Permit issuing office.
5�
CHECK ONE: INSURANCE 04'16ND [3 OTHER [I (Specify:)
I cer105?, under the pains and penalties ofperjury,
FIRM NAME: that the 'nform"Off on this aPPlicaden is &ue and complete
Licensee: LIC. NO.: A915PI.T-5
Signature
(1j'appolivable. en
ex�empt �in the lice�nse number line.) NO.:_A 7 11
Address: Bus. yefcclo.-ZZ
-,0, 'd I!U-i
Alt. Tel. No.:
4 Dipattmajji��
*Per M.G. L c. 147,,q. 5 -6 1, security wci! li� V luire. 9=
'i 111'Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not ol have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE.- $
0
14
Date .....
... ... .. ...... .......
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that ............... .........
has permission to perform ... kc) ........... 5&g. w
wiring in the building of ............ 7�?.!�� .....................
.................
at ............. 3 ..... ...... ............... . North Andover, Mass.
/ 2 5- ��'? T ic. No. A.0 Ov .............. I
Fee ..................... L LECTRI AL INSPECTOR
Check # 2->'o � 0
7939
60
.4
�L\ Commonwealth of Massachusetts Official Use Only
.A�
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfornied in accordance with the Massachusetts Electrical Code ( EQ, 527 CMR 12 00
(PLEASE PRINT IN INK OR TYPE ALL INFORA14 TION) Date:_ 1 ';, T-2 -� / o -7'
City or Town of. NORTH ANDOVER TO the inspJctor Of Vires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) It 3 'To �\ r� 5 -0 n
Owner or Tenant To
Owner's Address S
D &,F sc-c-t (�
Telephone No.
Is this permit in conjunction with a building permit?
Yes [:]
No
P (Check Appropriate Box)
Purpose of Building Rt 5 1 cJ-(q I ('(�x 0 (A fvk-"vf- OA
Utility Authorization No.
Existing Service Amps Volts
Overhead
0-
Undgrd No. of Meters
New Service 00 Amps /Zo Z14 Volts
OverheadD
Undgrd No. of Meters
Number of Feeders and Ampacity .
No. of Receptacle Outlets
No. of Oil Burners
FTLALARMS
Location and Nature of Proposed Electrical Work: 9,j--
L o cz4
No. of Gas Burners
N Det nd
-fc) Q nc�4-(,!n
rovw
Initiating Devices
No. of Ranges
ComnletiWn Allthe,1,17—
t -Alp —q
No. of Recessed Luminaires
Lua
No. of Ceil.-Susp. (Paddle) Fans
!LL eirispectoroirvires.
IN 0. of Total
Transformers K -VA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KV A
No. of Luminaires
Swimming Pool Above [I In-
El
lqo-.-OT Emeng-ency Lighting
grnd. ?'r n d.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FTLALARMS
No. of Zones
No. of Switches
No. of Gas Burners
N Det nd
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
—
No. of Alerting Devices
No. of Waste Disposers
Heat ump
Numbe:'
--
;�.50-
............
O&S—elf-Contained
otals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Localo Municipal
El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Water
Heaters KW
No. of No -.-of—
- No. of Devices or Equivalent
Data Wiring:
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Tot
Pelecom
No. c t
OTHER: 27�1 S-�CkA\ C�NQ)L-L:�- + - It t
A Ouch adairionai aetaii zy desired, or as requikd by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: - - Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE & BOND F] OTHER [] (Specify:)
I certi&, under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: N (n YN-P— k -e- C- -�,r � c C,� LIC. NO.: r -N J1
Licensee: NOYApu-k Signature LIC. NO.: JN k�
(If applicable, ente�e empt " in the license number line.) Bus.Tel.No.z.�- �-ol7a),-1
Address: 100 4("t-e^Ak
Alt. Tel. No.: "?S (- J 9�5 - Y-30
*Per M.G.L c. 147, s. 57-6 1, 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) El owner D wner's agent.
Owner/Agent
Signature Telephone No. PERMIT F
r I EE: $ / -Z
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rI-eltll W- , 11 /--L / 2- - -L/ -e 7
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Locatiorf
No. X/ Date ,z/- '9
,40RT#1 TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
—Building Insp9loir
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Date: April 2, 2009
THIS CERTIFIES THAT - " -
THE BUILDING LOCATED ON 3 Johnson Street
MAY BE OCCUPIED AS Marketing Service ftjd�ness IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: The Brick Store Co — Simon Group
3 Johnson Street
North Andover MA 01845
Building Inspector
Location3
lzz- '7
No. — - , f 2 Date
"ORTh
TOWN OF NORTH ANDOVER
60
Certificate Occupancy
$
of
CH
Building/Frame Permit Fee
$
Foundation Permit,Fee
$
Other Permit Fee.�',
$
TOTAL
$
Check #
2
Building Inspect/
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Brick Store Company
I — 3 — 5 Johnson Street
North Andover, MA
March 13, 2009
David D'Apice
The Simon Group
3 Johnson St.
North Andover, MA
RE: Proposed Sign over Doorway
Dear Dave,
I am pleased that you will be reusing the existing sign and simply repainting the face with the
name of your business on the same black smaltz back ground and the same gold letters.
The design you sent me looks handsome and in keeping with the historic nature of the building.
I look forward to seeing your name over the doorway.
Very truly yours,
Crowell Freeman, Jr
President
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McEvoy, Jeannine
From: SchruenderQaol.corn
Sent: Thursday, March 26, 2009 10:25 AM
To: McEvoy, Jeannine
Subject: sign at General Store
Hi Jeannine, It is okay to Issue the sign permit for The Simon Groug. Any questions please give me a call.
Thanks George
George H. Schruender
REALTOR
73 Chickering Road
North Andover, MA 01845
9786855000
Fax 978 686 5900
Coll 978 764 6000
Feeling the pinch at the grocery store? Make meals for Under $10. (http:/tfood.aol.com/frugal-
feasts?ncid=emicntusfood00000002)
V
3/26/2009
Date.. -.oh .....
k, r-15 TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that
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Fee--�.. 05.. Lic. No.
Check #
5746
........ North Andover, Mass.
...........
GAS INSPECTOR
MASSACHUSErIN UNIFORM APPLICATON FOR PERMrr TO DO GAS FTITNG
(Type or print) Date
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Buildina Locations Tn L
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Check one: Certificate Installing Company
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INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes EIr No E]
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy o--*- Other type of indemnity M Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
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14, TOWN OF NORTH ANDOVER
1$ ��-01-)-
iZ�- - J:1 PERMIT FOR GAS INSTALLATION
This certifies that
.............................
has permission for gas installation.,�;-� — f
in the buildings of ......................
at ... 2 -
North Andover, Mass.
Fee-�?..'. Lic. No.?4.39�. ",I ...... .........
. . . . . i. 7
GAS INSPECTOR
Check#./—,/ � 2, -
571,415
AASSACHUSETIS UNIFORM APPUCATON FOR PERA/Irr TO DO GAS FTITING
(Type or print) Date 161
NORTH ANDOVER, MASSACHUSETTS
Buildina, Locations
C,
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Permit # ��7-vs
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I have a current liability Insurance policy or it's substantial equivalent. Yes 0;1� No 13
If you have checked yes, please indkate the type coverage by checking the appropriate box.
Liability insurance policy 13/ Other type of indemnity Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
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quirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent 1-3
I hereby certify that al I 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 instal - s performed under Permit I ued for this application will be in
compliance with all pertinent provisions of the Massac. set eState,�GjaCode a N1 Chapter 9 2 of vs.
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.. ..... ... ...
Date ..... X// ...... .....
4,
'D ,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... .... 17 ........ .......
has permission to perform ........ 47. �n ......... . . . .... -.y .................
jo
,,4mg in the building of .. .5 ...
at�t ..... ..................... North And vil'r,
0
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F... Lic. go. ......... . .4 . . ..... ...... ...............
ELEcrRICAL IN ECTOR
Check #
5129
eMMMM5Xe-1,;P 07
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
.Official Use Only
Permit
Occupancy & Fee Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Elecirical Code 527 CMR 12:00
(Please Print in ink or type all information)
Town of North Andover
The undersigned applies for a permit to perform the electrical wdidescribed below.
Location (Street & Number iQ r (J ni Y'l to ;I Y.—, L /I
OwnerorTenant T-0LkJAJ a
Owner's Address 4/-rh C-,6-:W,2c�
Date4-15-014
To the Inspector of Wires:
Is this permit in conjunction with a building permit Yes No 0 (Check Appropriate Box)
Purpose of Buildin Utility ALdhorization No.
Existing Service Amps ............ Yofts
New Service —Amps_Vofts
4
Number of Feeders and Ampacitv 4
Cocation and Nature of Proposed Electrical Work,
Overhead 9 Undgmd 0 No. of Meters
Overhead 9 Undgmd 0 No. of Meters
I
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremenifts of Massachusetts General Lam
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - if you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (Ple2se Specify)
Estimated Value of. Electrical Work$, (Expiration Date)
Work to Start Inspection Date Resquested —Rough Final
Signed under the Penalties of perjury:
FIRM NAME
?Z_
��. 110J.
LIC.NO...2-5,12f76
'us. Tel No. T79' 490 -Itlq Z
Address Alt Tel. No.
OWNER'S INSURANCE WAVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Masi�chusefts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
(Signature of Owner or Agent) Telephone No. PERMIT FEE Vea�-
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 0
In 0
No. of Lighting Fixtures
Swimming Pool gmd 9
gmd 9
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Inftting Devices
Heat Total Total
No. of Diposal
No. Pumps
Tons
KW
No. of Sounding Devices
NoJ of Self Contained
No. of Dishwashers
- -----
Space/Area Heating
KW
DetectioWSounding Devices
0 Municipal 9 Other
No. of U'ryers
Heating Devices
KW
Local Connection
I
No. of
NO. of
LowVoltage
No. of Water Heaters KVV
Signs
Bailases
Wiring
No. Hydro Massage Tuds
— — —
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremenifts of Massachusetts General Lam
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - if you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (Ple2se Specify)
Estimated Value of. Electrical Work$, (Expiration Date)
Work to Start Inspection Date Resquested —Rough Final
Signed under the Penalties of perjury:
FIRM NAME
?Z_
��. 110J.
LIC.NO...2-5,12f76
'us. Tel No. T79' 490 -Itlq Z
Address Alt Tel. No.
OWNER'S INSURANCE WAVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Masi�chusefts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
(Signature of Owner or Agent) Telephone No. PERMIT FEE Vea�-
Name:
Location:
city Phone
F-1 am a homeowner performing all work myself
F-1 I am a sole proprietor and have no one working in any capacity
I am an employer providing. workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance Co. Poligy #
Compgnv name:
Address
Cily: Phone #:
Insurance Co. Policy #
=to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of crimi ' nal penalties of a fine up to $1,500.00
andfor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and com9ct.
Signature Date
Print name Phone #
Official use only do not write in this area to be completed by city or town official' f-1 Building Dept
FiCheck if immediate response is required Building Dept Licensing Board
E] Selectman's Office
Contact person: -Phone Health Department
Other
FORM WORKMAN'S COMPENSATION
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
011-k VK Ct t ( G -
This certifies that ............................................... . ........................
has permission to perform ......... 6,5f //
................
17 , 6
wiringin the building of ... ..........................................................................
at .......... e.1 .... ....... St .................... North Andover,.Mass.
Fee ... 3.5 .. : ......... Lic. Nca/,;V,� ........ .......... .............
Check # 171�� / ELECTRICAL INspEcTOR
4 9 tj 4
The Commonwealth ofMassachusetts Office Use Only -
Department of Public Safety Permit #
Board of Fire Prevention Regulations 527 CMR 12:00 Occupancy & Fee Checked
13/90 (leave blank)
APPLICATION FOR PERMIT TO PdRFORM ELECTRICAL WORK
All work to be performed in accordance with Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date December 12, 2003
City or Town of North Andoveri To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 3 Johnson Street
Owner or Tenant Brick Store Company (Care of Stevens Foundation)
Owner's Address Same
Is this pen -nit in conjunction with a building permit: Yes JF�K71 No F-1 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service
_Amps
Volts Overhead
=Undgrd
=No. of Meters
New Service
Amps
Volts Overhead
=Undgrd
=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 Lighting Fixtures
2 Swimming Pool
No. of Receptacle Outlets
I No. of Oil Bumers
No. of Switches
I No. of Gas Burriers
No. of Ranges
No. of Air Cond.
No. of Disposals
No. of Heat Pumps
No. of Dishwashers
Space / Area Heatir
yo. of Dryers
Heating Devices
-No. of Water Heaters
No. of Signs
No. of Hydro Massage. Tubs
INo. of Motors
Other:
New Bathroom
No. of Transformers
Generators
No. of Emergency Lighting Battery Units
Tons
kw
kw
kw
FIRE ALARMS
No. of Detection
No. of Sounding
No. of Self Contained
Local
INSURANCE COVERAGE: Pursuant to requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent YES FX NO I have submitted valid proof of the same to this office
YES X NO If
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE f —X BOND [ OTHER (please specify) 21212004
Estimated Value of Electrical Work (Expiration Date)
Work to Start Deeember11,2003 _Inspection Date Requested: Rough 1211212003
Signed under penalties of perjury: Final Upon Request
FIRM NAME Dumais Electric LIC. NO. 12170A
Licensee MarkA. Dumais Signature LIC. NO. 26665E
Address 8 Newport Street Bus. Tel. No. 978-683-9438
Methuen, MA 01844 Alt. Tel No. 978-685-4553
OWNERS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or it's
substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (please check one) 016)
Telephone No. Permit Fee
(Signature of Owner or Agent)
Location 3 T u s c) LA 3 —
No. `3 3 o"L- Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ o�6v
MU
Foundation Permit Fee $
Other Permit Fee
TOTAL $ /Z,' ao
Check #
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI$ RENOVATf2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED: //— lo2-
M
C(k��
SIGNATURE: /�
Building Commissioner/Inspector of Buildings Date
SECTION 1- SITE INFORMATION I
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning DiAiic—t Proposed Use
Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
RecjWred Provide Re�red Provided
Required Provided
1.7 Water Supply M.G.L.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 OWNERSHIP/AUTHORIZED AGENT
Historic District, Yes No
2.1 Owner of Record
fin 4�-(4
Name (P , nt) Address for Service
57/ V
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
f L) I i h Prty-, 4-
Liceri� Construction Supervisor:
6 -7
dr-
License Number
Address
Expiration Date
SignaWTe Telephone
3.2 Registered Home Improvement Contractor
Not Applicable 0
co �� / X�s
Company Name
Registration Number
Ad��f
?— 6 V
Expiration Date
Si 'elephone
T
M
1z
0
W
cli
P
M
0
z
M
90
0
I SECTION 4 - WORKERS COMPENSATION (KG.L C 152 6 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check
applicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) 0 1
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
74, h L5
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicani t
. . . . . . . . . .
Orn C, Mt
'AA
I 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) D,
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM[IT T
I,--- �-' �' J) 11 1)4" 7 )��A-ev' , as Owner/Authorized Agent of subject property
Hereby authorize to act on
MY beh�aIin all tters r work authorized by this building permit application.
1��t v, -) 2 3
11 �A�� ' �
Signiture of Owner Datl
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRABERS 2�u 3u
SPAN
DM4ENSIONS OF SELLS
DUVIENSIONS OF POSTS
DUVIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvINEY
IS BUILDING ON SOLID OR FELLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
31
r �Name
The Commonwealth of Massachusetts
Department of IndusNal Accidents
dga
Office of Inves dons
Boston, Mass. 02111
Wbrkers� COMPer'satiOn Insurance Affidavit
r-
Please Print
Uly /V, Lf*l n�* yr %/'
Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one writing in any capacity
EZII am an employer providing workers! compensation for ary employees mcMng on this job.
Companyname.
9 Y.Z. 4S'),�T
Comnany name:
Address
Phonelk
FaikwetoseCUF8, coverage as requiredunder-Secdon25A or MGL 152 can-leadtathakr;=i6m of erkwirmi
andfor one years' P ffes, a r., 4 1 h* 1 2 t 0 S1.
RKDRVMtA)aajb -
understand that a copy of this statement may belorwarded to *j&01W-0Qj-a
the office of Investigations of the DIA for cmwaga.
on.
I do hereby CVM5�wxfsr To Pam and penalhes Of PeflwY #AW ffiv ftYMMUM Prow* d above is &W aw awra Ct
I ------ Z-�- d
Print name, lkjl 14 V
-);z ,,,*
��a 1A -
Official use only do not write in this area to be completed by city or town
dkiar
city or
igg.
[jCheE* I mwwdiafe fesponse is mqurw StAWng Ekept
Board
Contact Selectrnar.Os Office
—Pt)one k Heafth Department
0 Other
V a
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL 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 IVIGL
c 11, S 150 A.
The debris will be disposed of in:
7 f?4� 61-��
Z --
(Location of Facility)
Signature of Permit Applicant
�2- z> Y
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this pr oject through the Office of the Building Inspector
10
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
-zAcmU51
This certifies that .............................
has permission to perform .... .....................
plumbing in the buildings of . . f ..........
at ... .................... North Andover, Mass.
Fee. . Lie. No.. 3.
.. .. ..................... ......
PLUMBING INSPECTOR
Check #
5228
,-It y
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSE-fTS Date
Building Location Permit #
Amount A
Owner
New Or Renovation 1-1 Replacement Plans Submitted Yes No
FXT'JRES
;P
z
(Print or type) Check one: Certificate
Installing Company Name d—T I S��/
ri Corp.
Address Partner.
El
Business 1�elep7one El Firm/Co.
Name of Licensed Plumber: b 4L.—
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy a Other type of indemnity El 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 11 Agent rl
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 Pem,4't ssued for this application will be in
compliance with all pertinent provisions of the Massac ttsLate Plumbi Code an hapter of the General Laws.
By:
>Igndture or 171censea F Inner
Title Type of Plumbing License
Z 6
lCity/Town Zb ,
APPROVED (OFFICE USE ONLY 1.1censwIN11moer master Journeyman
N2 2'04.8 Date .... // ?/ (
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... ......................................................................
has permission to perform .......... ........
wiring in the building of 74(
........................................................................
r 7— '7
at �) .7h, . ............ Z/, North Andover; Mass:/"/'
... ... .. . . .. .... . .... *** ' ***""* .... 11
Fee...-.7Yt-.A6 .. Lic. No. ................ /x�,
.. .......... I ........... .........................
Check # ";/ ELECMICAL INSPiCTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Jim (1U1VMUJVWLAL1" UP 1VL43k".L"U3E1 113 uIllue usu Only
DEPARTMENTWUMCS4FM Permit No. 7X -
BOARD OFFIREPREYEMONREGUMT10AS527CM 120
Occupancy & Fees Checked
APPUCATION FOR PERW TO XWORM ELEOWCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 cmR 12:0'
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Da
-4
T tthe�lnsp or of Wires-.�
Town of North Andover 0
The undersigned applies for a permit to perfbrm the electrical work described below.
Location (Street & Number) --u -JZ- �
Owner or Tenant 49
Owner's Address
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Purpose of Building /Le, 34 /, oc,- — -�- Utility Authorization No.
Existing Service Amps Volts Overhead Underground No. of Meters
New Service Amps Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity a 2- -, - � F c. -P 1tJ--'C ,
Location and Nature of Proposed Electrical Work -
No. of Lighting Outlets
No. of Hot Tubs
No. offransformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
ground
E]
ground M
V. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery
Units
No. of Switch Outlets
#
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Irtitiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Ot
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No, of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER
lha,,eaamulLabItyh&rd=Pbbcyml&gCanpidcOpaafi'mComaWcritsskstaMeWMkit
YES M NO 0
1ha%esthnftdvandpuof6f4m1otheOffim YES L_J�NO lf�u hmedudW YES, pbsemdr*theNxofw&aWbyduckinglhe
�, I ON 0��*
Wcrk,lDSt3t I/ /:?— 0 ) n i
r ' P4
T
Signcdmc�r ; na� ofpajLff y.
FIRM NAME _ 4 ) / �? - 4
Fiffiespo* �A"� Z) �L-
50*nDa1e
Etma1edV"cfl3ecftxalWak $
Ra# FM
---7'
, 7 LW=Nh -3�� s—j o',
00,
BusircssTeLNh
AIL Td Na
OWNER'S MYLAX)CE WAIVER, I am a�A=tAtheLjcffwdpes irt trmrj=wmaW"aksaWqmkitasmqmWbyMmmdu&GmyaiLmr.
anddrArnif WEAnonthisparnitTpficabonwaiviesihis M# UT01
(Please check one) Owner Agent 17 -
TelephoneNo. PERMIT FEEI 7� C)