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HomeMy WebLinkAboutMiscellaneous - 31 ROYAL CREST DRIVE 4/30/2018 (2) IL20 BUILDING FILE I. Date) .. in TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SSAC 11 is certifies that has permission to perform ........... ............................................................... wiring in the building o .............. R........................................................................... ......54 NorthAndover, ass. at N , ............................................... Fee.... /'Q.'.:.�*..........Lic.Nw�.CAL6 ELECTRICAL INSPECTOR Check 4t 13317 ommonausa o� aeedCkttdrs 6 official 1).se�Ojnly -- t'� t Permit No. � ,� ..1J2�itEM !!6 A��irR�irrvicrdb _ --- occupancy rend Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [ltev. 1/07) (leave Blank.) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfbrmcd in accordance with the Massachusetts Electrical C:odc(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR T.YP ALL XTOR1laMA.TIO.N) T)a.te: City or Town of: Nth(i� 6NJv- To 11m?lnspeclor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical workdescribed be 'tw. Location(Street&Number) 9,p & CM5N {�'S111�t�. ye , � r IBWU10J 1 _ Owner or Tenant k lt!� b 'i'clephone No. U-6'39-605'A Owner's Address 60 L LW-ST Ui\46 -- is this permit is conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building�P,,,Qi 4b" aAtv1'S- Utility Authorizntinn No. _-- Existing Service Amps / Volts Overhend lindgrd❑ No.of Meters New Service Amps / Volts Overhead[.j Undgrd❑ No.of Meters Number of.1 ecdcrs and Ampacity Location and Nature of Proposed Electrical Work: C��u�+ � rt�la_�.�.rrnt. �CGt� To �t?�I..nut; Q�1,n►�'� 1�-`C'�_..�tal�v�i 1�hGwYt"_ �'1n�� tr.Al,� �Ct�. +,ry ra.L�A�iS Conn letion 0'llie ollowin table rnav be waived!h the Inspector eif Wires,UsTQt N .of Total No.of Recessed Luminaires No.of Ccil.-Susp.(Paddle)rills Transfonuers K17A No.of Luminaire Outlets No.of Hot Tubs _.. Geln+crntors KVA Na.of Luminaires Swimming Pool Above ® n��- ❑ o.of smergcncy eg mg end. rnd. Batter Units Y No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Ruruers o.o Initiati)nti g D an n Devices No.of Ranges No.of Air Cond. ota No.of Alerting Devices 'Tons No.of Waste Disposers eat[lump um .er 'fans 1CW o.o Self-Contained p Totals: betection./Alertiniz Devices No.of Dishwashers Space/Areal Heating IOW Local(� Unieipal f�or"j 011ier r�alection No.of Dryers Pleating g Appliances>'liances KW T Security systems:* No.of Devices.or E guivalent No.of Water, No.of a.of Data Wiring: Reaters signs Ballad's No.of Devices or Equivalent No.Hydromassage Un latubs No,of Motors Total tip a ecommult enttnnsgrang: No.of Devices or E uivInt OTtirR: Aflach additional ileltii!it rkvirrd,or as required by the ftypector of 9/fres', Estimated Value of Electrical Work: (When required by municipat policy.) Work to Start: inspections to be requested in accorda.ncc with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for 1.he performance of electrical work may issue unless the licensee provides proofof liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certi Ces that such coverage is in force,and has exhibited proof ol'santc to the permit issuing office. CRECICONE: INSURANCE 5 BOND ❑ OTHER ❑ (Specify:) i certify,tinder tit pains acrd penalties of perlraay,thrat they infort"ation op daisapphrntinu is true acrd complete: FIRM NAME: Newport Ploctrlc LiC.NO.: A20803 Licensee: David McMullen Signature 11,11C.NO.: 1160813 (Ifapplicahle,enter "exennpl"in the!ceruse number line,) Rus. - Bas.Tel.No.'_401 293_Q527 Address: 200.1jIghpoint Ave. Portsmouth,Rf 02871 _ Alt.Tcl.No.:._a37-908.1193 *Per•M.G.L_c. 147,s.57-G1,security work requires Department of public Safety"S"License: Lic.No. OWNER'S iNSURANC'U WAIVER: I am aware that the Licensee daCS 1701 have the liability insurance coverage normally required.by law. By my signature below,I hereby waive this requirement, i am the(check one)Ox owner owner's agent, Owner/Agent Signature Telephone No, —.�.w.. .m.�� Puma I+EE, $ /a S 4 nq ,ey NORTH ANDOVER BM-DING DEP"TW TT `°q�TEnF �y 1600 Osgood Street �SSACHIlS�� . . • , North Andover Tel: 978-688-9545 , Fax: 978688-9542 13US ', 5FO"FOR TOWN CLEW DATE: .ADDRESS, 6T4 C ,ONjNGDISTP,-*fOT:_ TYI$OF JBUSIIES : f 0%ni-me BUMDING LAYOUT PROVIDED.- VES NO -e VA.l ABLEPARKMG SP.AOM: ZONMCIBYLAWMAGE: 'SES NO O BUILDING WSPEOTOR SICINAME f� BUSINESS FORM FOR TOWN CLERK ZAO Home Occupation(1939132) .An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use.of the building for liznng piuposes. Home occupations shall ' 'incIude,"bu't tot'lfinited to the following uses; personal services such as firr ished by an artist or instructor, but not occupation involved with motor vehicle repairs, beautsr parlors, animal kennels, or the conduct of retail business,or the manufacturing o£goods,which impacts the residential nature of the neighborhood, 4. For use of a dwelling in any residential district or multi-fhmily district for a home occupation,the following conditions shall apply: a. Not more,than a total of three (3) people may be employed, the-home occupation, one of whom shall be the owner of thd home occupation and residing in said dwelling, b. The use is carried on strictly within the principal building; c. More shall be no m-Wrior alterations, accessory buildings, or display which are not custemary with residential buildings; - d. Not more than twenty-five(25) percent of the oxis itig gross floor area of;die dwelling unit. so used, not to oxceed one thousand (1000) square feet, is devoted to'such use. fn connection.with such use,there is to be,kept no stock in trade, commodities or products which occupy space beyond these limits; e. There will be no display of goods or wares visible from the street; f The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the ehrterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any affior way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design_not custarnaxyr in buildings for residential ignatare Date 5 Date................. ......................... `4 NOFITM, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ;,SSACHU�t�g This certifies that ..!..`!. ........... -'...... �......{..c has permission to perform .I 1 wiring in the building of........... ✓.y)..�..P.................................................................... HL at .4............................ ................................. .................................>>North Andover,Mas . Fer ./ .. .� .....Lic.No?..a. 3 ......HO..yl.�l..���,,,r ��r� .2r!P... / EL'ECTRICA PECTOR/" Check# '��� r Commonwealth of Massachusetts Fii/99J fficial Use Only Department of Fire Services �� BOARD OF FIRE PREVENTION REGULATIONS and Fee Chocked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusotts Electrical Code(MBC),527 CMR 12,00 (PLEASE PRINT IN INK OR TYPE AL4 INFO City or Town of: No'f TION) Date: By this application the undersigned gives notice Ns°©er tr To the Inspector of fres: Location(Street& Number) ton to perform the electrical work described below. Owner or Tenant A ma, Owner's Address V U Telephone No, q 7,r 6. �� ere �a 7a©c Is this permit in conjunction with a building permit? Yes 11 - a S t 3 Purpose of Building L�UJ C 1,1 N0 (Check Appropriate Box) Existing Service Utility Authorization No. Amps / Volts N v •---- / -_ Overhead❑ Undgrd�] No, of Meters —•��-� .___-i Amps / Valts � Overhead ElUndgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Eloctrical Work: f—•- 2 tkTS IN 0.tJc�. ��.i I a � 1�1T\VQ. t ttte c,.,re a :u �� �` Gtr �r letion o 'the ollowin table ma be waived b the Ins ector o Wires. No.of Recessed. No.of Cell.-Sus P.(Paddle)Fans o.o Transformers o a No.of Lighting Outlets KVA No.of Hot Tubs No,of Lighting Fixtures Generators KVA eve Swimming Pool n- o,o rnergency g ng No,of Receptacle Outlets rad, ra " No.of Oil Burners d. Bette Units No.of Switches FIRE ALARMS No,of Zones No.of Gas Burners o, o etoc ori an No.of Ranges otal Initiatln Devices No,of Air Coll No,of Alei No,of Waste Disposers p um er Uns ns rtng Devices eu um No,of Dishwashers Totals; o, o e - onta ne etectlon/Alertin Devices b Space/Area Heating KW unrc a No,of Dryers Heating Appliances Local onnecttion ❑ Other NOF.o star r Heaters KW . 010 010 KW ecuNo.of Devices or Equivalent Signs Ballasts Data Wiring: No,Hydromassage BathtubsNo. f Devices or E uivalent No.of Motors Total HP a ecommun cat ons r ng: y'� f '1M¢�T OTHER; �j Gt2C Yi L �( r No.of Devices or E uivalent INSURANCE COVERAGE; Unless waived by the owner, no permit for the performance of le��' eYM� ��� .lJtach addlJlona!detail!f'deslred,or os required by the Inspector oJ,Wlres. t the licensee provides proof of liability insurance including`bompl0ted operation"coverage or its substantial equivalent.issu The undersigned certifies that such coverage is in force,and has exhibited proof ti same to the permitsubstantial work may lent. unless CHECK ONE-; INSURANCE [�]' BOND M OTHER issuing office. ❑ (Specify;) Estimated Value of Electrical Wor 3���. i_ (When required by municipal policy,) (hxptrahon Date) Work to,Start; Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the 4__Y__ pains and penalties o er u p FIRM NAME: New �,. fp � G that the information on this application is true and complete, Licensee: LIC,favv Address: (Yapplicnhle enter "exempt"in the 1icet',re number line,) Slgnatur ` LIC.NO,: U Address: D OWNER"" Bus .To].NO,- ue, -� S iNSURAN EVA,, I am aware that the Licensee does no,ha0e�tile liability required bylaw. By my signature below,I hereby waive this requirement. I am the Alt.Tel, co 3 Owner/Agent y la (check oninsurance coverage no�mally Signature wnor owners a ant. Telephone No, PE FEE; $ (} f7 I Ile h 014,35achusetts DCPfPtly?ent of,tlldustrial Aecidents Offrce of Investigations 1 Congress street,Suite 100 Boston, MA 02114-2017 wivivomassgovId a Workers' Conapcnsat>ion l,ln.sulranee Affidavit: Builders/Contra.ctors/EIectrlic>lalns/Plumbers ADWicant T>rtforllnatxo>a )[ease P>t�>int Ltr >ibX 3117e(Basinesslprganization/Individual): _ L Address: C M r1 4tr1 �/l City/Statcl7ip: l3 l'1''lld 10&2 +I Phone Aou an, employer? Cheep the appropriate box: 1. 1.am a employer. with-- _ 4• D I am a.general contractor and I Type of project(required): employees(full and/or part-ti nMe).'� have hired the sub-contractors 6, [1 New eo;nstraction 2,0 1,am a'sole proprietor or partner listed on the attached sheet, 7. []Remodeling ship and have no employees 'these subcontractors have working, for me in any capacity, ennployees and have workers' 8' ❑De molthon 4 ns [No workers' comp, insurance comp, insurance.k 9• wilding addition required.] 5. D We are a.corporation and its 10 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MUL 11.© Plumbing repairs or additions insurance required.]t c, 152, §1(4),and we have Ilo 12-El Roof repairs crtiployees. [No workers' 13-El Other ' comp. insurance required.] Homeowners who submit this rs' *Any applicant that chocks box#1 must also fi11 ottt the section below showing their workecompensation policy information, l' afdnvit indicating they are doing all work and thon hire outside cohtractors must submit a new affidavit indicating such, $Contractors thstt check this box must attaahcd an additional sheet showing the name of the 3ab-c0ntractors and s cmployces. If'tile sub-contractors have employees,t)xey must provide their workers'comp,policy number, tate whdther or not those entities have 7 am ail eltiployer that is providirig Nyorkers'coriipensation insurance for my employees. Below is the policy andjob site iri formation. Insurance Company Name: "4 � Policy#or Self-ins.Lic.#:,�p J Expiration Date: CSI a�dL,S— Job Site Address;., aVi�! /"!✓ 7— City/State/Zip; V,r !�/ 'S► ' Attach it copy of the vvorkers'cOmPen$Ation policy declarations page(showing the policy number and expiration date), Failure to secure Coverage as required.under Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a fitie up to$1,500,00 aad/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 agaiiist the violator,• Be advised that a copy of this statement may be forwarded to the Office of lnvestigati0t1s of,the,DIA for insurance coverage verification. .l do hereb cerci t,limier th am rad enal#es o let•irry that the in nrnration.prarided rrGove is true find turret!. Si nature; — — — — — -- — —Date e� QffIcial rise only. Do not write in this area,to be completed by city or town ofjciaJ. City or Tovvn: Permit/License# Issuling Authority circle one). Y( ) 1, )Board of Health Z,Building Department p ent 3.City/Town Clerk 4,Electrical' 6, trical Iles Clfher attar 5. Plumbing lumbirt In Spector spec#oi- Contact Person: )phone#: Q $a*=COMMONWEALTH 4F'M SSA HIIS • • • a • -: E]�fCTRICIANS ]SSUES THE FO.LLOWtNGf€ENSE :AS .. R'EGISTERED 'MASTER. ELfC:TR7C!'AN N.EWP..RT `ELECTR I E tl AV i b ;A MCC IJ].L �,�WEtti �� 0]852 4026 � 20803..A rP cOMMON1�11FJXLTH© CHl3 ETT ELf�TR]CIANS .t-SSif'S,?THE FOLLOIV] G L`]GENS:E AS iG°.iOUR]�EYMAt ELECTRI.C..�A pAY1k0 A MCI�IU,LLEN tq, 76 K 11fxH L.1 PSTREET:' p��'TSi�1E}UTH f�1� 02$] 502 s AC Q. �--- CERTIFICATE OF LIABILITY IN�U NE /P013 OP ID: LS RAN C E DATE(MWDCriYYy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLTHIS bE , 01/00/2014 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed. if 3 the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate do certificate holder in Ileu of such endorsements. UBROGATION IS WAIVED,subject to PRODUCER es not confer rights to the DF Dwyer o van D.F. Dwyer Insurance Agent 38 Bellevue Avenue P �------_-.__— NBwport,RI 02840 ` ' `401-846-9629 Da el F.Dwyer III a ;dfd did er,com c Noa�401-846.9629 _ INSURE 8 AFFORDING COVERAGE _ INSURE _ NAIC N D Newport Electric Construction --" INSURERA;Foremost — Corp INSURER B:Scottsdale Insurance Com an ._._--.. 200 High Point Ave,Suite B6 INSURERC:Beacon Mutual Insurance --- 41287 Portsmouth, RI 02871 — INSURER ; INSURER E; COVERAGES CERTIFICATE NUMBER: F THIS 13 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 'BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TYPE OF INSURANCE ...... GENERAL LIABILITY POLIC NUMBER uMlTs A X COMMERCIAL GENERAL LIABILITY SCP006046448EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE �OCCUR 12/30/2013 12/30/2014 — 4s [L4t14s_L .. 3 ^300,00 MED EXP An one arson S 10,00 PERSONAL 8 ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO- LOC PRODUCTS-COMP/OP AGG S 2,000,00 AUTOMOBILE LIABILITY S A ANY AUTO OMB NED SIN LE LI IT ALL P005046448 E arci enl ___ 1,000,00 AUTOS OWNED X SCHEDULED SC12/30/2013 12/30/2014 BODILY INJURY(Per _ AUTOS Parton) 3 HIRED AUTOS X NON•OWNED BODILY INJURY(Per accident) 3 AUTOS PR PERTY D GE a UMBltl.'LLA L1AB X OCCUR ._,.._.. S B X EXOE88 LU18 CLAIMS-MADE BSOO19598 EACH OCCURRENCE 3 0 b TE N 1213012013 12/30/2014 AGGREGATE W014�R8COMPENSATION 3 6,000,00 AND EINPLOYERs,UABIUTY 3 C ANY PE PRIETOR/PARTNER/EXECUTIVE YIN N WC STATU- OTH. OFFICER/M EMBER EXCLUDED? ❑ N/A 68861 01/18/2014 01/18/2016 S . ,ER. (Mandatory in NH) E.L.EACH ACCIDENT $ 600,00 If yyes de TI N under E.L.DISEASE-EA EMPLOYEE 3 600,00 DE �R PTI NOF PERATtONS below A Empi Prac Llab SCP00604644812/30/2013 12/30/2014 E.L.DISEASE-POLICY LIMIT $ 600,00 60,00 DESCRIPTION OF OPeRATiON3I LOCATION91 VEHICLES (Attaoh ACORD 101,AddlUonal Remarks Schedule,If more spaos Is rsquirsd) CERTIF CATE OLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Insured's Copy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REP Re86NTATIVE Daniel F. Dwyer III ACORD 26(2010/06)6) The ACORD name and logo are registered marks2of CORD D CORPORATION.. All rights reserved, 37 1 v a. � 3 � y ✓ 5 � 6 ✓ � ✓ �' 3 /U ✓ 1! '� , i ✓ ��� /,� -z - ' V 03b1 Date.... 4, TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 4L ,SSA CHU This certifies that ... . . ... ....... . ............Z has permission to perform ....4��&Xf- ................ ........... wiring in the building of North Andover,Mass. SP �V Fee.14 Lic.No.f.1 74............ ELECTRICAL SPE d Check # Commonwealth of MassachusettsOfficial Use Only MIEW j Department of Fire Services Permit No. to �e 1 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to beP erformed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10-13-2011 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) 50 Royal Crest Drive Building#,j 7 Owner or Tenant Royal Crest Estates Telephone No. Owner's Address 50 Royal Crest Drive Is this permit in conjunction with a building permit? Yes No X (Check Appropriate Box) Purpose of Building Apartment Buildings 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: Upgrade Emergency Lighting r Completion of the o wing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp. No.of Total / (Paddle)Fans Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- E] No—.of Emergency Lighting 6 rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I 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 No.of Waste Disposers Heat Pump Number I.Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances ham, Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent ' No.Hydromassage Bathtubs No.of Motors Total HP 'Telecommunications Wiring:No.of Devices or Equivalent s 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 ofelectrical 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 x BOND ❑ OTHER ❑ (Specify:) 3-21-12 (Expiration Date) Estimated Value of Electrical Work: Work to Start: 10-17-11 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: Stilian Electric,Inc 108 Tenney St.Georgetown,MA 01833 LIC.NO.: Al 1067 Licensee: Kari Gonsiorowski Signature LIC.NO.: E31598 (Ifapplicable,enter"exempt"in the license number line.) Bus.Tel.No.: 978-352-9994 Address: 108 Tenney Street Georgetown,MA 01833 Alt.Tel.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 PERMIT FEE: $125.00 Signature Telephone No. �'� �� �yam- �` r t M