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Home My WebLink AboutMiscellaneous - 300 FOSTER STREET 4/30/2018 (2) / { 300 FOSTER STREET J 2101104.8 2 J i f I I I I I I I L i A i LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 March 13, 2015 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845-2210 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845-2210 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139 SECTION 3B Claim has been,made involving loss, damage or destruction of thero ertY captioned below, which P P P may either exceed $1,000.00 or cause Massachusetts General Laws Chapter 1 p 43, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139 Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: VISHNU & DIPTI V SHAH Loss Location: 300 FOSTER ST NORTH ANDOVER, MA 01845-2210 Policy Number: PHOO100717155 Date of Loss: 02/04/2015 Cause of Loss: Water LA File Number: MA-2-27754 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Hope Brunette Adjuster LaMarche Associates,Inc.-800-349-1525 ; Page 1 of 1 I MERR ENGINEERING I ERV CES INC. [LECTUCRE OGS M ° HMD VL° I� Engineers • Surveyors • Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 DATE JOB NO. (978) 475-3555 ATTENTION TO Fax (978)) 475-1448 �LiGA v\ �G " yV/J� Ina RE: '404 D Y1 ►� lid ��G�L� �o FoS-rte `� WE ARE SENDING YOU D Attached `❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION C_ icy THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval oyour use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS COPY TO SIGNED�� If enclosures are not as noted,kindly notify us at once. Location :000 S S No. Date —al _ Z)3 d NORTH TOWN OF NORTH ANDOVER F � p Certificate of Occupancy $ CH SA 9 Buildin /Frame Permit Fee $ �6 s�cNut Foundation Permit Fee $ Other Permit Fee $ TOTAL $ . Check # 7S-/`I 16541 - Building Inspector f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: ® a,r, DATE ISSUED: SIGNATURE: C BuilTnj Commissioner/1for of B 'Idings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 30 ° r-4e2st -3 Map Number Parcel Number O 1.3 Zoning Information: 1.4 Property Dimensions: �n Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Regifired Provided ReqWred Provided 1.7 Water SupplyM.GL.C.40. 54) I.S. Flood Zone Information: ].8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT Historic District: Yes—No x'11 2.1 Owner of Record rA" 5 A �SfY� C Name(Print) Address for Service: �13 Signature Telephone 2.2 Owner of Record: �) Name PrintO Address for Service: Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Liiensed Construction Supervisor: Not Applicable ❑ �e_ C,� S60 l /Va rA Licen ed Construction Supervisor: O I A N � ``� License Number 72 W I/ Z �LL� I""77►/TT 11 Address (�Q (,c f d 0 J yGV Expiration Date Signa Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 41-1e_C4 Company t4aiiie �✓�' / �/�l//'lrG(/ Registration Number r Address r ad Expiratio Dat z^ Si nature Telephone Y 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 building permit. —Signed affidavit Attached Yes....... No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 7tion ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Pr9posed W rk: v v SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3.+4+5 Check Number SECTION 7a OWNER AUTHORIZATM TO BE COMPLETED WHEN OWNERS AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/ uthorized Agei of subject property Herebyorize 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/ Cthonzedsubject projyJ r Hereclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge andief Print Name 03 Si at 16rof Owner/ e t Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIWNSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE z - w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02 911 Workers'Compensation Insurance Affidavit Name Please Print Name: / Ji E2 Location: 2d' .. . fft City L, AL N/t 11- Phone # 3 90'6 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employ Providing workers'compensation for my employees working on this job. Company name: A / C— r ' Address l/��" � 'V G7T 71 .�� -57 Ci1hr Phone Insurance.Co. Poli, # w"T Company name: Address_ Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties afa fine and/or one years'imprisonments vitalLas_ciW4xmaitiesjoSheSnan�fA-STOP]�RIC_ORQERand_arme-d 1:QO.QQ.a UP to$1.500.0(T understand that a copy of this statement may be forwarded to the office of investigations of the DIA for coverage nst me 1 verification. /do hereby cerffY un pWWand Pel ft irrfon mdW provided above is true and correct. Signature pie Print name 4� l N a Pint=# 57.9,f 3 W✓ Official use only do not write in this area to be completed by city or town affiaar fifty or Town Eermit/Licensinct Building Dept ❑Check I immediate response is required ❑ LkeiWnq Board ❑ Selectman's Office Contact person: Phone#. ❑ Health Department ❑ Other Window&Siding HI TECH PREMIUM SOLID VINYL SIDING InstaAations,Inc. INSTALLED BY FACTORY TRAINED TECHNICIANS http://www.windows-siding.com NATIONAL TOLL FREE 1-800-851-0900 MASS REGISTRATION #118836 DATE 5-Z-0 3 SOURCE CONSULTANT HOME TEL. ' 6 � WORK TEL. MR./MRS. -f4 THIS AGREEMENT, made and entered into bet een CH WINDOW&SIDING INSTALLATIONS, INC hereafter referred to as a con ractor AND K � ADDRESS/STREETo4 toS-{�-S� CITY��STATE ��Zlp hereafter r - referred to as owner. THE SAID CONTRACTOR hereby agrees that it will furnish all labor and materials necessary to install the following described work at premises located at: JOB ADDRESS CONTRACTOR agrees to start described work on/or about s a er In ngs and complete described work in about - 0 working days.-�— 9 Y � dam- � DELAYED INSTALLATIONS: DO NOT START INSTALLATIO BEFORE: CONTRACTOR shall not be held liable for delays due to causes and our The following work includes all labor'and materials needed to complete your job in a workmanlike manner. Area to be sided � t U�$Q- Insulation to be used v«r C. ' Size '3 p Siding Brand C O r0*olor o � / Siding Style .5 // Corner Post O Regular ide Color/U I OWN Trim Coil // 0 P.V.C. O Aluminum Trim Color 4A Fascia Treatment Soffit Treatment h . Window& Door Casing reatments Shutter Brand Amount Color / XN Gutter Style Uar& q Color % PAYMENT POLICY ipe Style +' pp (� // It Iolor J �T• 00 Total InvestmeS E-Z Blocks Amount Color White 25%Deposit 0. 0 U 'Dryer VentIV 4kv Amount Color White 25%Payment at Halfway Point O D Gable VenSizeColor 50%Balance Day Of Completion �� bu THE OWNER SHALL PAY FOR THE WORK 0 In Cash or Check Upon Completion 0 Hi Tech Will Make Bank Arrangements 0 By Bank Modernization Loan 0 Owner Will Make Bank Arrangements You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller, which may be his main office or branch thereto,provided you notify the seller in writing at his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. Ematenal'sl is guaranteed to be as specified.All work to be completed in a workmanlike mannero standard practices.Any alterations or estimate deviation from above specifications AUthoflZed $IgnatUre tra cost will be executed only upon written orders and will become an extra charge over the estimate.All agreements contingent upon strikes,accidents or delays beyond our Date ner to carry fire.tomado and other necessary insurance.Our workers are fully covered by Compensation Insurance. NOTE:This proposal may be withdrawn by us if not accepted with days. An interest charge of 1 1/2% per month (18% per year) will be Date o eptan - -O added to any amount unpaid after 30 days from invoice date. Signat In the event of default in payment of this order or any part thereof and the account is referred to an attorney for collection,the purchaser agrees to pay reasonable attorney fees. 'l Signature NQRTIy Town of Andover . 0 Wk No. 04ik ~ " _ 0 t- CHICH LA dover, Mass., COW19 ORATED 02 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT 40 & A0.4 ........... ..................................................................... .. . Foundation has permission to erect......V.10V .......... .... ..... ..... . ........................................... Rough .Y.'......... buildings on ...�A.0.10..........?V7 0. . . to be occupied as........... A0.,q..........r 1/ jC60&0a#jft4k x%, I . Chimney ..... .. .............. .. ..............................i...........3........................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. ./apt/ is 1 %2 d /6 4P PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Per ft. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .......... ...$000010 ................................. . ........................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Tinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Official U_sey0 ly ; Permit No. ��[ I Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to bePerformed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date -,VX/ U 3 To the IrApect.6r of Wires: Town of North Andover The undersigned applies for a permit to perform)the electrical work described below. Location(Street&Number 300 /—O S40 2 S Owner or Tenant1 Owner's Address S 0--YVU— Kj- n fr,..k L Appropriate Box) lity Authorization Und and ❑ No.of Meters 7 '.�! l g Date....... . ....... . ....... I Undgmd ❑ No.of Meters t N RTM 1 3a;•';�`"�°;."°oX. TOWN OF NORTH ANDOVER PERMIT FOR WIRING I f 41 • Total No.of Transformers KVA SS�cMusf� i j Generators KVA This certifies that (% + f f i No.of Emergency Lighting ..............................................'................................... Battery Units has permission to perform ......l(....I /, (I./ F i FIRE ALARMS No.of Zone ................. ..........r..... ......................... No.of Detection and ring in the building of /� '' /1 Initiating Devices ................................................................................. W .. , No.of Sounding Devices at............:.1�r.�................................................... .... ,North.Andover,Mass. No./of Self Contained -. v , Deter Soundi Devices l 17/ Detection/Sounding Fee.. . . .......... Ltc.No. a.� :... ............... ... ..:. . `>'i1i r*. s1..9 T s i ❑ Municipal ❑ Other . .. ....... . ... ELECTRICAL INSPECTOR Local Connection L Low Voltage Check # Wiring i 4636 INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or 14 substantial equivalent YES NO = miffedvalid proof of same to the OfficeYES= NO = you have the ed Y plea indicate th a yer ge by checking the appropriate box INSURANCE = BOND = OTHER._ (Please Specify) 1 L ^� i ion Date) Estimated Value of lectrical Work$ / o 17 Work to Start Inspection Date Resquested Rough Final 01X, Signed under th naltIT 21 u : ,/ n�� e G LIC.NO. Y J[9 FIRM NAME �/ v� l� Licensee /`� /' Signature XIICC.NO. Bus.Tel No. v 7 Y r 7 Addres 0`, v (l Aft Tel.No. OWNER'SMINIMACANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) 'l 0 Telephone No. PERMITTEE $ V� V (Signature of Owner or Agent) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02919 Workers'Compensation Insurance Affidavit Name /} Please Print Name: Location: od � $ City -A t V r 1� Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any Capacity 1 am an employer providing workers' compensation for my employees working on this job. Company name: C4 S=r Address • �J � N Ci Phone# v �� Insurance.Co. Poligif# Company name: Address City. Phone#: Insurance Co. PoliGV# 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'imprisorrnenLas YMLas_cty 4xmakiesb-thelwn4-aBT'QPllAORK9RDERand afee-ef.($1-ODM)-a�r.againstme. I understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for coverage verification. I do hereby certiry unaler e ' and na of peq that the information provided above is true and correct. Signature Date � U Print name Pbme.# 76 7 Official use only do not write in this area to be completed by city or town official' City or Town Perr*Ajcensing Building Dept []Check I immediate response is required .0 Licensing Board E] Selectman's Office Contact person: Phone# Ej Health Department Other Town of North Andover Office of the Conservation Department Community Development and Services Division 27 Charles Street q�s�+=HUS�� Alison McKay North Andover,Massachusetts 01845 y Telephone(978)688-9530 978 Conservation Associate Fax( )688-9542 September 8, 2003 Dipti Shaw 300 Foster Street North Andover, MA 01845 RE: Construction of a Brick Patio in Replacement of a Deck at 300 Foster Street Dear Ms. Shaw: This is a follow-up to our office conversation on 9/3/03 for your request to construct a brick patio in replacement of a deck at the above referenced location. I had asked if there were wetlands within 100 feet of the proposed work. You had indicated that the patio would extend no further than the previously existing deck and that wetlands were very far away from the proposed work. At the time of your office visit, I was unable to pull the file on your property because it was with the Health Department. I had subsequently given you an approval to construct the patio, given that the work would be minimal and it appeared as though the work would be outside of the 100- foot wetland buffer zone. Following your office visit I was able to look at the Board of Health file, which had a plan showing wetlands 100+feet from the house. Although the plan was not current(1979) and was not an as built, an inspection was necessary to confirm that the patio was approvable without the required conservation permit filing. This inspection was performed on 9/5/03. Upon inspection, I measured that the wetlands were approximately 95+feet away from the closest point of work. Please be aware that this work does in fact fall within the 100-foot wetland buffer zone and any work within this buffer zone would normally require a filing with the North Andover Conservation Commission pursuant to the Massachusetts Wetlands Protection Act and the North Andover Wetlands Protection Bylaw. However, I am confirming authorization for the construction of the brick patio only since the work is minimal and 95+feet away from the wetland resource area. Any future work within this buffer zone may require a filing with the Conservation Department. Please feel free to contact me if you have any further question or concerns in this regard. Sincerely, Alison E. McKay, Consery 'on Associate Cc: File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Ilio-2 S+eA 6 , 1 , � s I r1 b fr i 'se i 4 f 3fig i t f3-".U' ►3 .L t � ; 4 , I , -DJe— X1'7 't - Date../l..'.. �........ t f NOR711 1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��Ss�cHu E�'h ,J!�%'r. ti/ s This certifies that - . ........,.........�..... ....................... has permission to per/Lr �, M.wl'l.I y .j�-..,.��..... {.,�..>I wiring in the building of.I.! .�f./....... !/t ............................... +► „�0:1. ..+?. . ...................... .North Andover,Mass. at 0 N...� Fee.4.45 k�).... Lic.NoA ................. '��ll;2!.,G✓C� 1�.1,// ELECf'MCALINSPECTOR Check # 5423 Official Use Onl _ Commonwealth of Massachusetts Permit No. Department of Fire Services r Occupancy and Fee Checked „? BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMF,12.0 (PLEASE PRINT IN INK OR E ALL , 0 ATION) Date:_ City or Town of: To the Inspector o Wires: By this application the undersigned ives noti his her inten 'on to perform the electrical work described below. Location(Street&Nu r) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a,huilding permit? <;Yes..❑ No (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: Installation of Security system Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Lighting Fixtures Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection Heating Appliances Security Systems: No.of Dryers 1; pp KW No.of Devices or Equivalent ! (p No.of Water KW o.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent i No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: ( No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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 ❑ OTHER ❑ (Specify) (Expiration Date) Estimated Value of Electrical Work: 5 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: cesLIC.NO.: I q3�(' Licensee: John S. Bassett Signature LIC.NO.: 1533C (Ifapplicable, enter"exempt"in the license number line) Bus.Tel.No.: 603 594 5928 Address: Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Lid,9fisee 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ `14 4 e Commonwealth of Massachusetts Official Use Onl ti � •^ Department of Fire Services Permit No. ' BOARD OF FIRE PREVENTIONREGULATIONS Occupancy and Fee Checked 411r17 [Rev. 1 I/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M (PLEASE PRINT IN INK OR 2,&1 CM ALL FO ATION) Date: 71. City or Town of: To the Inspector12 o Wires: By this application the undersigned fives noti his her inten ' n to perform the electrical work described below. Location(Street&Nu r) Owner or Tenant ., tTelephone.�No. L O Owner's Address 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 ❑ Undgrd❑ No.of Meters New Service Amps / _Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system Com letion of the followin table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs_ Generators KVA j No.of Lighting Fixtures Swimming Pool Above El In- ❑ o.o mergency 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 No.o Detechon an No.of Ranges No.of Air Cond. Total —Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons I KW No.of Self-Contained Totals: Detection/Alertincy Devices No.of Dishwashers _ Space/Area Heating KW Local ❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of WaterNo.o No.of Devices or Equivalent l(p Heaters KW No.o Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E OTHER: uivalent Attach additional detail if desired,or as required by the Inspector of Wires. 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 ❑ OTHER ❑ (Specify:) i Estimated Value of Electrical Work: - (Expiration Date) (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: HnJJj -LIC.NO.: Licensee:_ ,John S. Bassett Signature LIC.NO.: 1533C (If applicable, enter"exempt"in the license number line.) Address: Bus.Tel.No.: 60 524-5-928 OWNER'S INSURANCE WAIVER: I am aware that the Lic, see does not have the liability insu ance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ i