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Home My WebLink AboutMiscellaneous - 31 QUAIL RUN LANE 4/30/2018 31 QUAIL RUN LANE l 210/060.0-0122-0000.0 i Ak Cemmerce Insurance- -the Commerce Insurance Cempanys,, C� Citation Insurance CempanysM Members of The Commerce Group, Inc.- CLAIMS DEPT. 11 Gore Road,Webster,Massachusetts 01570 (508)949-1500 www.Commerceinsurance.com August 13, 2013 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: GLENN J KILADIS/DIANE K KILADIS Property Address: 31 QUAIL RUN LN Policy#: YY7902 Date of Loss: 08/03/2013 Filet HJHM49-YTKJ07 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. ANGELA LUHTA Telephone: (508)949-1500 Ext: 15371 Claim Representative I, Property Toll Free: 1-800-221-1605, Ext:15371 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above,by first class mail. August 13, 2013 COIlU Crc Ccmpanies ....COME GROW WITH us CIC 254 (Rev.4/95) MAIL L96 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Glenn & Diane Kiladis Property Address: 31 Quail Run Lane Policy Number: YY7902 Date/Cause of Loss: 8/3/2013, Sewerage Back-Up File or Claim Number: 28376-M Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, 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 and claim or file number. Mike Peterson 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. Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Date. �,(�oIOZ-. . . . . ..... MORTM TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SS HUS IL This certifies that . . . has permission for as insta�,4 ion �� +�-.?`? ^y.�P 8 //in the buildin of . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . at . . . � :�. . `�. . . . . . . . , North/Andover, Glass. Fee. �'. Co. . Lic. No% it. . . . . �wr"0 '. . . . . . INSPEC`(SR Check# WSo� 8230 Date 71eph Z� . 9469 NORTH , TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 41 SSACMUS� This certifies that . . ?'?. . /U'n i has permission to perform a.. . . . . . !e-- . . . . . . . // �. plumbing in the buildings of . ./'��4a cl(5. . . . . . . . . . . . . . . . . . . at . . .�. . . . . . . . . . . .. No h Andover, Mass. Fee.�,.60. .Lic. No.Cf.�Pd • . . . '441Z.� . . . . . . . PLUMBING I PECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , CITY - -N-O.Qv: 'M-— MA DATE '�'t, 12 -�;PERMIT# Le JOBSITE ADDRESS `� �°�� -�!+�h -_---; OWNER'S NAME-1.��o,hQ, �•�k q ��S .._._-_.". OWNER ADDRESS ..--' --- - ... �M� __ ? TEL ') __SZS _ S TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATfONAI L ,j RESIDENTIAL PRINT _ CLEARLY NEW:: RENOVATION:'`; REPLACEMENT:t9 PLANS SUBMITTED: YES: NO'� FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE " DEDICATED SPECIAL WASTE SYSTEiN - DEDICATED GASlCdUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM - -. DEDICATED WATER RECYCLE SYSTEM - DISHWASHER DRINKING FOUNTAIN - --" FOOD DISPOSER E FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN - SHOWER STALL " SERVICE I MOP SINr{ - - TOILE T URINAL - - - - - - - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - - - WATER PIPING OTHER --- E INSURANCE COVERAGE: I I have a current liability insurance policy or its substantial equivalent which meats the requirements of MGL Ch.142. YES)( NO f IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY i BOND OMER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the f Massachusetts General Laws,and that my signature on this permit application waives this requirement I CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby cert that a!)of tl1e details and information I have sitmitted or entered regarding this application are;true and accurate to the gest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in corn plfa all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER'S NAME rQ.a Zr�ck �(`t1 o x17 LICENSE# Z�S ' SIGNATURE ___._._.___.__..._. .gam... -.--' MP 'A JP CORPORATION k; 'i;,�W PARTNERSHIP:-__t# __- LLC COMPANY NAME �. .C`�.. Q1s�rc��►rc, eft ___: ADDRESS:. CITY ' :STATES Z1P t'�ZcBS _.._.. TEL FAX CELL EMAIL ' r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE-O&LY FINAL INSPECTION NOTES e Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: S PERMIT# PLAN REVIEW NOTES '4 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FRYING 1NORK CITY '"- - --------- ----- —------ ---{ MA DATE PERMIT# JOBSITE ADDRESS °�,\ �±\�'1 __-;OWNER'S OWNER ADDRESS ShhnL i TEL 11 -� �,� �q. �6 y 7 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I RESIDENTIAL, PRINT CLEARLY NEW: -"= RENOVATION:`' REPLACEMENT: Kj PLANS SUBMITTED: YES . NO K APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR _ GRILLE INFRARED HEATER _ LABORATORY COCKS a MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT _ . .. TEST UNIT HEATER -47 UNVENTED ROOM HEATER WATER HEATER OTHER , INSURANCE.COVERAGE I have a current liabli insurance policy or its substantial equivalent which meets the requirerrtenfs of MGL.Ch.142 YES 'K'NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY !X! OTHER TYPE INDEMNl1Y ? BOND OYI♦NER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application rraiYes this requirement. - CHECK ONE ONLY:-- OWNER--- - AGENT-- --_ _ SIGNATURE OF OWNER OR AGENT I hereby certify that ail of the details and lnfarrnation i have submitted or entered regarding this application are true and accurate to the gest of my knowledge and that all plumbing work and kstaitations performed under the permit issued for this application will be In compliance Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. --_d=7!§�t\� PLUMBER GASFiTTER NAME LICENSE#i' % �M SIGNATURE -- "- PARTNERSHIP' LLC MP # X MGF i_. .. JP--J JGF; LPGI CORPORATION�K # Z � r- COMPANY NAME G- M - I ADDRESS CITY STATE"1-•�. Ca`r� STATEZZIPO_Z�S6.5_ TELLi4l..-G3C1 FAX' ?CELL! ;EMAIL; ROUGH GAS INSPECTION_NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes .No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i i i I i I - ' Date ...7�...... ............ e NORTH 1 3?;•_t;�`'° "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING M o �� • a SS�cHus� .ice L This certifies that . ` has permission to perform ...... x........... -- ;......... wiring in the building of. - 4 :.:. mss ................................................... i alk.........:::- ... ....................... .. ......... .North Andover,Mass. Fee ?'. ...... Lic.No'' ! . ?' t ELECTRICAL P Check # i 85 �, � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: ` -- ')y City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentio to perform the electrical work described below. Location(Street&Number) 0 U At,f' ' Owner or Tenant I_-Q k/ ! ) A. 1�� Telephone No�U - Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of BuildingUtility Authorization No. Existing Service ACC- C 1 rd Amps / Volts Overhead Und g ❑ 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: Completion of the folloud table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above �["Ir-n o. o mergency ig g d• d. ❑ Batte Units -— No.of Receptacle Outlets No.of Oil Burners i FIRE ALARPvIS idc. of Zones 1 No.of Switches c:6— No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. TonTotsl No.of Alerting Devices No.of Waste Disposers Heat P!p Number Tons KW No.of Self-Contained Totals: __........_......._ ~ -' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of water No.of No.of Devices or Equivalent Heaters ' No.of Data Wiring: Si s Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total gp Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0 . G (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 10 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 certify, under the pains andpenalties of perjury, that the information on this application is true and completes FIRM N �LEC Licensee: (/ Signature LIC.NO.: (r :big (If applicable, enter"exempt"in th licedse nu r line.) LIC.NO.:%6 Address: L, ,4,At0 ZLHNM �� Bus.Tel.No. 1=S(o0 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt l L c.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one ❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ jam � d� The Commonwealth of Massachusetts U, ! Department of Industrial Accidents c •�`r Office of Investigations 600 NZashington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print LevMy Name(Business/organization/Individual): )� Address: AJ UkN C '� VV—/) e V City/State/Zip: {><M .A Phone #:r�.� �X4 t Are you an employer?Check the appropriate box: I.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(requited): e O'loyees(full and/or part-time).* have hired the sub-comsactors b• ❑New construction 2. I am a.sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me.in any capacity. workers' comp. insurance. [No workers'comp, insurance 5. [1 We are a corporation and its 9. Building addition aired l 0.❑Electrical required.] officers have exercised their repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No-workers'comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' • comp. insurance required.] ME]Other Any applicant that checks bozo#I must also fill out the section below showing their workers'compensation policy information t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'co^p,p^i:c;inr nation. I am an employer that is providing workerscompensation insurance for my.employees. Below is the information. policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: ( Q Job Site Address:-� ' ( >�!,j M/ City/State/Zip: �(L Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the fonn of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or tnmstee of an individual,partnership,association or other legal entity,employing employees. 'However the owner*-of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or.to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,nofthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy;please call the Department at the numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permi0icense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ` Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-QS www.mms.gov/dia Date....../...'2..... df�... HORT1i TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ��ssHcHus�� This certifies thatG��r.P�G Lid ............................................................................................. has permission to perform ...........G.:...v ;,!...... ................ wiring in the building of........... .!'1.1� .�f.�j......................................... 31 Q!i 1 L/l�/� ��.................... .North Andover,Mass. at.................... ... ....... Fee.. ............- pp ELEcrmcAL INspwrOR Check # 3 -73 7- 7969 f Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 71n� VVJ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ,14w City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 I U V 4 1(_ k/,/ flko Owner or Tenant 6Y.Liz 1y C3 Telephone NoG�)R -1, Owner's Address M Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Ho vi- Z Utility Authorization No. Existing Service)JJJ_ Amps (J / t Volts Overhead ET/ Undgrd❑ No.of Meters j New Service Amps / Volts Overhead❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �1 ��rn/ L ctu,1 2y �2�IvL Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool AboveElIn- ❑ o.o Emergency Lighting rnd. rnd. Batte 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 InitiatingTotDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat PSP Number I Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal El ❑ Other Connection No.of Dryers j Heating Appliances KW Security Systems:* No.of Devices or E No.of Water No.of No.of uivalent Heaters KW Si s Ballasts DatN irinof Devices or E uivalent r No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent e �'�/. Attach additional detail if desired, or as required by the Inspector of Wires. ((J) Estimated Value of Electrical Work: , all (When required by municipal policy.) Work to Start:J/>,,,,/j)y OV 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 cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC.NO.: 6601A Licensee: n tJv Signature LIC.NO.: (gyp (If applicable, enter"exempt"in t e license number lin ) Bus.Tel.No.:C ? / Address: �/� ZL [�'S--meq— �� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts i ! Department of Industrial Accidents �. Ogee of Investigations 640 Washington Street Boston, MA 02111 s www.ntass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name (Business/Organization/individuai): L Address: City/State/Zip:�2��l�r;r� /�� 'I Phone#: . &03-S66 -13y 3 Are yQu an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1 4, ❑ I am a general contractor and l 6, ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for mein any capacity, workers' comp. insurance. q, ❑Building addition r [No workers'comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself,[No-workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t .employees. [No workers' comp. insurance required.] 1317 Other Any applicant that checks bo)[#I must also fill out the section below showing their workers'compensation policy information, 1 Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheetshowirg the name of the sub-contractorsand their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for ary employees: Below is the policy and job site information. Insurance Company Name:_ F-/ASte—✓✓ T/VS (� Policy#or Self-ins. Lie.#: Expiration Date:5U1y U�j Job Site Address: Vl � ►C(�>✓, � City/State/Zip:4�0C Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigatio s of the DIA for insurance coverage verification. R I do here a fy nand penalties of perjury that the information provided above is true and correct Si ature: i Date. A/`' �� U%)( Phone#: �o Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing:Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner'-of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance'coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if A necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the l members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not-the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their Self-insurance license number on the appropriate line. City or Town Officiais Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permidlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitAicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-OS www.mass,gov/dia Date..! `..�!.�. .... .. OF NO DTH ,� tf 3? �` TOWN OF NORTH ANDOVER O � 9 - PERMIT FOR GAS INSTALLATION �,SSACHUSEt This certifies that . . rr . AG' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . in the buildings of . .I. /s f.g at . . ? . . . . . . . . . .. North Andover, Mass. Fee. . . .. . Lic. No..l.` .;.° .'. . . . . ... . . . . . . . . . . . . . . . . GAS INSPECTOR Check# 6 � GO MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:—Kl- c/—� MA. Date: � Permit# Building Location: � Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ C FIXTURES zz y O YCn U y } J 2 1-- W r z d W z ~ z fn cn _iz Q Q 0 z 0 Q rn x a w ~ W Q U) �4 cn OJ X o0 MQ W o Q Q z 0 o W z W J Z v a Q Y LL 2 Op x z Q W �: a. Y a = W W W Q m m o 0 0 2 Y J J � 0 0 � D < < < O SUB BSMT. jBASEMENT 1 FLOOR . 2 NU FLOOR 3 FLOOR 4 1 H FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 1 H FLOOR Check One Only Certificate# Installing Company Name: ti c Ali c� � ❑Corporation Address: Q 230C /d City/Town: /y- �' State: AlIq Business Tel: 7 `� (r�'_�3�4 Fax: 9�(�- fp 0'�-�,3G 6 ❑ Partnership / &KFirm/Company Name of Licensed Plumber:--- INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes❑ No❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 0— Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have su mitted(or entered)rega ding this app' ion are true and curat to )est of my Knowledge and that all plumbing work and installations perfor ed under the permit ii sued for this p ication will bei compl' nc i all Pertinent provision of the Massachusetts State Plumbing Code d Chapter 142 of fie General L By Type of License: Title lumber nature of Lice ed/Plum er City/Town ❑ Master License Numb / 631 6 / APPROVED OFFICE USE ONLY 'Q-Journeyman Date..... . ,...... .. fiOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION '4 1y,'o,, c.••tth SSACMUSE This certifies that . . .1�q. l . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . t!t-. .�f . . . . . . . . . . . . . . . . . . in the buildings of . . . . !.!. ► . J. . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . ., North Andover, Mass. Fee. .f �. . . Lic. No..13,�� L. . . . . . . a.._ . Vti�.-^. . . . . . GAS INSPECTOR Check 5377 MASSAC Typ tro «type)- _UNIFORM APPA-na FOFfp -TO Doc, NG . Pe� � own a Nart,o-:_ ,u tj le Type of Occupancy New ❑ Renwzuonz-O Replacemenco- Plant s&,xw .Y eig . NO:13_ a = ap: a z: C ai. rf c. a e Q x. o a �. _ o I } Z. to r ;� art :a _ D J }. '_ .C- Idp: C1691 S C aD .StiR..'8S'MT. � U . JISEMKT .'LST FLOOR 4 - 2lt0 FLOOR 3R0 FL60a 4.TH`FLOOR.. `STk4LOOR . :4TH Fd00R TTN FLOOR dTN FLOOR.. Instep Ing Cnm Address CCIC;Or1e;: -J`N 4 �.xyyl,� e4- ��,'�• rn a n a l SI O Cocporation- Business Telephone - —r _ ❑ Partr . Name of Licensed Plumber or>cas Fitter.. �2Lken S {�cdd� � FlmvCQ Q JNSURANCE=.C�0 RA J have a Y< I s�'equ eftwhich meets, a raquice+ner�ts.of_ Ii you havt: lvlGL-Ch. 142.- d°°d_3 n� efte-coverage-by ghe�.�. A liability. _ �tyP�ci,dem� C1_ � a OWNER'S INSURANCE ChaPter- 142 d-the. LAVER I arra awara;that,thelieeo o - = =taws,-acidt:mY sigrnttue on coverage required-by- General wabAm-this requirement Check one: 8ignat a of OwMr�r Owner Agent, - �rO Agent:Q -y!�h,e�r,e,�b�y�cer*. that an of the datails and.intoanration 1.haaee ""�^'w5re a�bW aR pkm�p walrand i u'b tted{or entered)in above appl" and Peniraeaat Provi"U of the tdo,Gas 00 Pfd under the per nQ issuod� toahe best-of my Massactaauetts State Cas.Godo grad ChaPter 142 of the Geaasral Pliianot wot at. - T of License_ G I Titie Plarrraber fu 30 Of Gty/rown License N umber APPW raeyrnaA !lHLOV1f FORbfflCE;'!t>ZEHLY.` FINAL INSPECTION SKETCHES PAb.Oq 'S.S tNSPE;CTION FEE Hoe, i APPLICATION-IFdP O.zRMITTO d0 OAS,PITT.INQ 14PE.0KBUILdIN10. 'li : . PLUMDEh.Oh�dASF1.�fER' , , �i�l. tea• • „J.:{... , d11T .ti .�0..��.. di r o.As INs>rkcTbo 5 0.1 "pRTM TOWN OF NORTH ANDOVER I RMIT FOR PLUMBING �� SS�CMUS� 7 This certifies that . . _. .�y9/r!.�. . .�. .,.�„. . . . . . . . . . . . . . . . . . . has permission to perform . . . .L . . .7. . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of `A.'. 5. . . . . . . . . . . . . . . . . . . . . at. . . . . . . ..1 . ., North Andover, Mass. Fee. .1.1 . '. . .Lic. No.. . 1 6,(. . . . . . . . . . . 1 . . . . . . . . . 1 PLUMBING INSPECTOR Check # G7 .l�,. nspection Of Plumbing MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT.TO p0 PLUMBING(Print or Type) MBING rr✓t�(L Mass. nate �03 - Permit # Building Location Owner's Name New Q Renovation Q Type of Occupancy Replacement Plans Submitted: Yes 0 No O FIXTURE t W Y J N O X QzO) S CA Ic 0 Cc o fl • 3 J N ¢ a J p Q u. H NX W C Z O O N 2 Z K F tt W O t SUS-HSMT, 03 0 t HASEM2NT 1ST,FLOOR 2N0 FLOOR 3RO...FLO"OR 4TH.FLOOR STHFLOO.R 6TH FLOOR t . ?TM FLOOR aTH FLOOR Installing Company Name ` � Address U - �� Check one: Ge ca YA Corporation Business TelephoneO Partnership Name of Ucensed Plumber d O Firm/Co, INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements ,If you haveschecked No of MGL Ch. 142. lCg3, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Q Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does_ n0�� the Insurance coverage required b Chapter 142 of the Mass. General Laws, and that my signature on this permit ensapplication waives this requirement. Y Check one: qu cement. nature o ner or , ner's.A ent Owner C Agent ❑ I hereby certify that all of the details and information 1 have submitted for entered)in knowledge and that all plumbing work and installations perfiirmed under the perm ; d tar Pertinent provisions of the Massachusetts State Plumbing Cede and Chapter 1q f e appy 'on are true an accurate to the best of my a icatLon w e in compliance with ail gy Gan Title ignature o ;cense um of Cit /Town Type of Ucense Master Journe IIPP yman O Ucense Number u � 3i� eFLOW FOR OFFICE UQE ONLY � II 1�tNIII NEPE LOYts '3KITT1:`NE1 IEEE 'ROQA ES.IN ptQ114NO N0. APPLICATION-F0111!ERMLT TO 00!•tUMe1N0 , UNDERGROUND ROUGH COMPLETE ROUGH ` FINAL INOPACTION ,4. DUE PLUMOING INlkPECT.OM . , � MA 5-^�A( �|°��c � T�� Vx��X!��'�� : . M of -____ -_- _- . '---' fill 4uilding Location @,)61 [IOLA ^�~ oc New 7 Renovation Fj Replacemei Plans Submitted FIX r 10 LI UI 7- 1ST FLOOn 317113 rLooii 4TR FLOOR STH FLOOR TTK FLOOR STH FLOOR I Tt_ (Print or Type) Check one: [ertiUcaLu Installing [- | Co/ p'Address ILI) ______._ _ ---------'--�—T- ----�� ^~ Business Telephone: 71 Name of Licensed Plumber or Gas Fitter / vW V�- Insurance Covera : Indicate the type of insurance coverage by checking t}lc appropriate box: _ Liability insurance po| 0t>�cr ty|/'� of i/�dcl//rliiy I— ] li'//ld i | Insurance Waiver: 1 , t��-un]~�signcd, have been mnd'! aware that the licensee of ------ one o� the above three insurance cnveragcs this application any n ' ------- [--� �--- Signature o--------- wrier/agent of ro�,crty Ovv/ier i__] /\ijc,`i Ixoehvr^,txYthat All "rWoaemJ,2^« |"w,m*ivrI b,,^ wopixw (or ,"/peu)it,"\'nr^rp/ip^"^w"m`°awl,mv*",tc0the bt*v<n.y a Date. . . . . . . . . . . . . . . . . . . . . MORTM TOWN OF NORTH ANDOVER Q�tt lE° ib 1�0 0 ° op PERMIT FOR GAS INSTALLATION �9SSACMUSEt This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . . . . . . f,ic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: F`" J r- _ Date./J. ./�... ..... .... .. .. i NORTH TOWN OF NORTH ANDOVER pf 4«a o '6,4, 3? 'a PERMIT FOR GAS INSTALLATION p f 9 3 • �,SSACHUSEt �7 This certifies that . . . . -w. .—�uy`'�`?. • • • • • • • has permission for gas installation .? . . . .t "`:�. . . . . . G' in he buildings.of . . . . . . . . . i—�,. . . . . . . . . . . . . . . . . . . . . . . at . . .�/. .... . . . . . . . . .!` � .. ...., North Andover, Mass. FeO�' . . . . . . Lic. No.. . . . . . . . . . ,. F1 45� G GAS INSPECTOR'JT WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Vj �A 1 LAPP CATON FOR PERMIT TO DO GAS FITTING or print) .PARCEL Date l;� _ �� — 19 FORTH ANDD 21.--- Building Locations Permit 9 / Amount S c� Owner's Name G/� !` /9�/�S New❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ rn ^' raj Z 1J 'C -f z m U z Ci Z :. Z '� :9 i z -t w :r n x z C C SUB-BASEII ENT BASE .M ENT 1sT. FLOG R 2N9 . FLO U R 3RD FLOOR 4T'1I FLOOR ' 5TV1 FLOUR 6T If . F L U O R 7T 11 . FLUOR 8'T 11 . FLOG R (Print or type) y�f y� Check one: Certificate Installing Company Name U j S s flu c�i da , �t C� f /TC'S��j` ❑ Corp. Address G rel c` PI,d9// K ❑ Partner. T st-2,75 618 ,7 Business Telephone ❑ Firm/Co. ti Name of Licensed Plumber or Gas Fitter , // /� (l' /� Lt INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ED NO If you have checked ves,please indicate the type coverage by checking the appropriate box. Liability insurance policy �' Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I have submitted(or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Bv: Signature of Licensed Plumber Or Gas Fitter Title ❑—Plumber ��S y City/Town ❑ Gas Fitter License i urnoer F-3—vtaster APPROVED wi FicF us,-ONLY) ❑ Journeyman MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING f (Print or Type) 01 Mass. Date "' a 19 Permit # �1 -Y Building Location fAl 1 e—L) ARD Owner's Name' iy4 y: ' Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No [� N N ¢ N tZ¢11 N Nmc7 ofxN¢ V W Y Y¢m a cc 0 N W O O QZ O- Cr ¢ ¢ O a¢� !FW W O W A- Z sn O > W cc W W N J z Q r ¢ ¢ W ¢ W H W N _ t7 N ¢ Y Q W Q ¢ F- �" >- N m Z O 7. W O tll t 'x O C7 Z LL D 0 J U ¢ > a a H O SUB—BSMT. BASEMENT ISTFLOOR 2ND FLOOR ' 3RD FLOOR 4TH FLOOR STHFLOOR 6THFLOOR 7TH FLOOR STH FLOOR Installing Company Name Check one: Certificate Address UL2 Corporation i ❑ Partnership Business elephone_ — -10A Firm/Co. Name of Licensed Plumber or Gas Fitter zk��,r INSURANCE COVERAGE: I have a curr nt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes, ] No El If you hav checked ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of Indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify tt alLof the details artid information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and tat alt_pluinbing work a_ndipstallations performed under the permit issued for this application will be in compliance with all pertinent,proviliions of the Massachusetts'State Gas Code and Chapter 142 of the General Laws. T e of License: Title l Plumber Signa of n ed Plum as Fitter Gasfitter City/Town- << r : I Master license Number APPROVED APPROVED.(OFFICE USE ONLY) _J Journeyman 1 + Date.. . ... �f HO oT e 1�o TOWN OF NORTH ANDOVER 0 p PERMIT FOR GAS INSTALLATION O� iq SSACHUSE 1� j I This certifies that . . . has permission for gas installation . . . . . .... . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ! . . . . . . . . . . . . ., North Andover, Mass. Fee. . . Lic. Io.. . . . . . . y0 GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File Date... �6 AP�... N23 - //....... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SS CHUS This certifies that ......... ........C/f C r& ............................................... has permission to perform ............ .......................................... wiring in the building of........ ....................................... at..............7.1 C)U L7 ....... North Andover,Mas�s-�-- Fee.. Lic.NoAR—At.........N� ....... A- A ELECTRICAL INSWI:��R'* Check # 76 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer . ' Date... No 1565 , 4147 0) C 1\U Of NO oT � TOWN OF NORTH ANDOVER o p PERMIT FOR GAS INSTALLATION Ln 4 i s o a �9SSACMUSEtth CA -0 n This certifiesth ,,'' r r" has permission folgasn anon ,t!-add.1. .e,�m��'. . . a in the buildi of . . Alp-tq?0 at .1-Zida. . . . . . . . . , North �> veer,�Mt►ass. Fe .fjf�&. :-n . Lic. No.. . . . . . . . . . ,.,�.' . . !.'. . . . . L4/J/t4/4IV/0 GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File The Commonwealth of Massachusetts FOR OFFICE USE ONLY Department of Public Safety PennitNo.- BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Receipt No. 8 . APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work will be performed in accordance with the Massachusetts General Code.527CMR12:00 (PLEASE PRINT IN INK OR TYPE ALL FORMATION) Date City or Town of &C r-�11 /�t'1 SOU To the Inspector of Wires: s. The undersigned applies for a permit to perform the electrical work described below: Location(Street and Number) _21 0001d R(it'1 10ac; Map: Lot: Owner or Tenant Gi)e boon K Zone: Owner's Address .50-Vim_. Is this permit in conjunction with a building permit? Yes❑ No (Check Appropriate Box) Purpose of Building t� Utility Authorization No. 01-17F6 Existing Service 200 Amps I b Volts Overhead❑ Underground 2'0'� No.of Meters New Service Amps / Volts Overhead ❑ Underground❑ No.of Meters Number i�f Feeders and Ampacity Location and Nature of Proposed Electrical Work �a ky- ► iyt 56tJ No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above grnd.❑In-grnd.❑ Generators KVA No.of.Receptacle Outlets No.of Oil Burners No.of Emerg.Lighting Battery Units No.of Switch Outlets No.of Gas Burners FIRE ALARMS No.of Zones No.p,rRanges No.of Air Cond. Total Tons No.of Detection and No.of Total Total Initiating Devices No.of Disposals Heat Pumps Tons Kw No.of Sounding Devices No.of Dishwashers Space/Area Heating KW No.of Self-Contained No.of Dryers Heating Devices KW Detection/Sounding Devices No.of Water Heaters KW No.of Signs No.of Ballasts Local❑ Muncipal Connection❑ Other No.of Hydro Massage Tubs No.of Motors Total HP Low Voltage Wiring OTHER: INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent.YES ❑NO❑ I have submitted valid proof of same to this office.YES ❑NO❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box. INSURANCE❑ BOND❑ OTHER❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start VO 2— In Date Requested:Rough Final Signed under the'pena ties of perjury: . FIRM NAME ra �/e_C_ C 2 LIC.NO. A1j119 Licensee r is CSG Signature LIC NO. Address d7%y-y-, DevP1 k/e G l 92_3 Bus.Tel.No.97 r?-M —6?-" Alt.Tel.No. OWNER'S INSURANCE WAIVER:I am aware that the Licensee 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) � Telephone No. PERMIT FEE$ (Signature of Owner or Agent) INSPECTION RECORD Date Notes — Remarks Inspector 1