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HomeMy WebLinkAboutMiscellaneous - 314 MASSACHUSETTS AVENUE 4/30/2018 314 MASSACHUSETTS AVENUE ` r/ 210/016.0-0041-0000.0 r 90 3 �- Date . . . . . . N°R'M TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUS� P This certifies that . 3© . . . .��H . ... . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . plumbing in the buildings of . . �.� . . . . . . . . . . . . at . U.c. . . . . . . . . . . . . .. North Ando r, ass. Fe�360P. .Lic. No.. 776. . . . . . .;.6 . . . . . . . PLUMBING INSPECTOR Check # 1�2 5-7 N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: N o r h A hd Ay p r MA, Date• Permit# Building Location A'V c Owners Name: V ,a n t i Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional[❑ Resic1entiaIrffPr1_ New:❑ Alteration:❑ Renovation: iV Replacement: Plans Submitted: Yes❑ No❑G FIXTURES DEDICATED Z SYSTEMS Z Z 11, Y U Z 'n a Z e ¢ u w o 0 Q W W ? 1- _W Z F" iA N Z Q C' W p 0 Co Q w o Q Z = Q Z in d E x Q N f- ~ N W W 0 0 a W W _Z Y. O 3 U j > LL O a Y a 2 w FW- w o2f O in 3 H a m m o o LL i Y g 3 0° x ° Q W a a a u a WLn Ln 0 a -SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ST"FLOOR 6T"FLOOR 7T"FLOOR 8"FLOOR L v T,e-).Y i I(& R dr� Check One Only Certificate# Ins ng Company Name: k e 1 �1 � ct/ El Corporation Address: G'►- •Q 1^�/i �� � ��j('j State: [ El Partnership Business Tel: 60 'S 03 C)Itt � I Fax: �' W1 Q0 P Firm/Company Name of Licensed Plumber: _ ATS INSURANCE COVERAGE: I 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. ❑ 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 ZMassu4sesgenera s,andthat my signature on this permit application waives this requirement. Check One Only er or Owner's A Agent Owner Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title [dumber Signaturgof Licensed Plumber 71 City[Town (--Master APPROVED OFFICE USE ONLY ❑,lourneyman License Number: Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS . • ,£ •�' • IMPORTANT NOTICE BOARD LICENSED AS A MASTER PLUMBER s PERMITS FOR PLUMBING AND GAS FITTING INSTALLATIONS ON STATE OWNED OR USED FACILITIES MUT BEAT ISSUES THIS LICENSE TO It OFFICE OF HE STATEILED BOARD.THE TYPE JOHN B SHEA IC fro -M .62 PARKERVILLE RD SOU.THBOROUGH MA 01772-15,18" :,., 758960 .7863 05/01/12 258960 Fold,Then Detach Along All Perforations I Fold,Then Detach Along All Perforations A COMMONWEALTH OF MASSACHUSETTS "`• ;• • • IMPORTANT NOTICE BOARD I . KUMT PL LICENSED AS A JOURNEYMAN PLUMBE INSTAI��aT°oNs onMi sTaTe owrGiE�OR USEDI ISSUES THIS LICENSE TO FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. TYPE JOHN B SHEA 7 —J 62 PAR KERVILLE RD ;�, ; SOUTHBOROUGH MA 01772-1518 . 4 i . 758961 14029 05/01/12 758961 -Fold,Then Detach Along All Perforations The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name (Business/Organization/Individual): Jp�t V� S e A Address: (,,. �, f Q ti ` k �r � � 11 City/State/Zip: Sc,c;-f },n r© tj A Phone#: S O 9 - 101 --p11 Are you an employer?Check the appropriate box: 1.ElI am a employer with 4. ElI am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6' ,❑New construction 2. I am a sole proprietor or partner- listed on the attached sh%et. # 7. I.yl Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.9 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.] 13.❑ Other t *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. I 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'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 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. Sienature: Date `bbt 10 / 1 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 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 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-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 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 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license 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 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Location 317 No. 9 Date MORTM TOWN OF NORTH ANDOVER O 9 i • }is Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � , w Check # �d 15 5 '1 Building Inspect TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r�``.`-�;,i g �,�car�$:� 'rf tykr rw. .� € ,,''s �•� ",js xt L � ? �.�._ �.4 :;;_ g�wvr�{ �'k'fs'��i� .R�rr.ru r;�_ � y�_ BUILDING PERMIT NUMBER. DATE ISSUED: M SIGNATURE: Buildin Commissioner/1 uildings Date SECTION I-SITE INFORMATION z 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O 11Y MAS-AVE . Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required Provided Ptquired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infonmtion: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT q M 2.1 Owner of Record EVA SA&EP-64AW 13PI MA.55 0 t Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O z Signature Telephone M SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ DAVID 0,hSTR1C D4F_ REG i- SG . Licensed Construction Supervisor: p o aC s UJ7D n) S T JU I},�-,� p V J License Number Address on Signature Telephone Expiration Date icr 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M .�a o S uo N ST, , 1& /nl ' F9, Address �. � �e /0 z Expiration Date Si nature Telephone s 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.......0 No.......0 SECTION 5 Description of Proposed Work checkapplicable) New Construction ❑ ,ExistV1 Building Repair(s) ❑ Alteration Addition ❑ Accessory Bldg. '❑ Mmolition. ❑ Other ❑ Specify A ;! Brief Description of Proposed Work: .S"TA I >P ¢- 9 E k 6 a F SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicant ' r, 4P, s r a°s +•, bad_- ss.,. z 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 e 6 Total 1+2+3+4+5 14 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN * OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize 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 1, DAV I J) CA-071 12E as Owner uthorized Agen of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief p V12 C S Print e Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS 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 DAVID CASTRICONE ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS FREE ESTIMATES HOME IMPROVEMENT CONTRACTORS REGISTRATION NUMBER 104569 In Kingston 603-642-5990 In Haverhill 978-374-7314 In North Andover 978-688-9638 In Boxford 978-887-6147 7 Hillside Road, Boxford, MA. 01921 231 R Sutton St., No. Andover, MA; 01845 I/we,the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor,to furnish all necessary materials, labor and workmanship, to install,construct and place the improvements according to the following specifications, terms and conditions, on premises below described: (� Owner's Name............�7.v.,v ,.......�.1..� Job Address........6Pf.....1. o, S.S........4.jA e. �,f ..................................................City... ... .p.,.. a.t�„l'.......State......MA............................. SPECIFICATIONS ` ' c ...IJ4M.. ................. t`�. ......... .zt.r. 1, . .�. . .. .../.s cam .. ...... .. ... ... 1 �..................... .'Xt . . ..Q.,...... .......... .f.. ..... ........� .. . ............... ...........D. ... o.�.s ...... .( T............ .�. .......,..�,1. � ......... .r..,. ........�J. . .......D.a.....�..�r�.....�. ...................................................................................... 1 � f .e.rao .........r,<a t.. . ......... .......s'p.......�? ............ .......... L . . . �a.)........, ...... T.r.......W . r... . . ...ip-,...................................................................................... . . . ........S�.a/-Cr .... I.. V. .:..................... .. ..... ................................ ,....... .. ..C„�t.......If.. L(?..f .......... '( t ...........................`...............................e .. ? . .... .......���r��U'"".. .........r � /, 1. •... -yK ..ter ..................................,, �..... . . . ..�.. . ......L1.0..V-L.0...................... . ... ... ..:e. 4.9-10................................................................................................. .................................. . �,:..... ..�..�. )..... � ................-.........1. � ............ ........................................ Materials and labor to cost$ ................................................................. Payable ...�,. ft... ... trr� Contractor will do all of said work in a good workmanlike manner. Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation a a completio as requested ca by the contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid Immediately due and payable. It is agreed that it permitted by law contractor shall be paid by the owner(s),all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor;and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties. The undersigned warrant(s)that he is(they are)the owner(s)of the above mentioned premises and that legal title thereto stands of record in his(their)name(s). PROVISO:This contract shall be void and of no effort if credit approved of owner(s)is refused. There are no representations,guaranties or warranties,except such as may be herein Incorporated,if any,nor any agreements collateral hereto,nor is this contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Receipt of a copy of this contract is hereby acknowledged,and It is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is in operation. IN WITNESS WHEREOF,the parties have hereunto signed their names this .....��.. .. ............day of .0- .. . 3 ......., Accepted: Al. Signed... Lx.-:::.... :...:.:Own : ......�� .............................. Signed...................................................................................... Per....:. /f.:YJ owner • •� ..: `.J.....�= ............................ RepresentativeSigned...................................................................................... Owner • //fIle" /ff/r/:fI/��! f� ��r....r rr'/r/r..✓.��' Board of Building F2cgulH1ions Hud titrudard� HOME IMPROVEMENT CONTRACTOR z Registration: 10469 Exaira;ion: 7/14/02 Type: PRIVATE CORPORATION DAVID CASTRICONE ROOFING, S MaCP �astricone 7 Hillside Road Boxford,MA 0192' Administr:uur a Town of North Andover ti tAORTH q O �SLIO ,6 x 0 Building Department o 27 Charles Street North Andover Massachusetts 01845 * _ a► (978) 688-9545 Fax (978) 688-9542 4SSgc�U DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit 9 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in/at: ,x- Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. de—,AORTH E Town of d 0 _ o�A �oCN,��D, dover, Mass., S DRATE D P?Y`� 5 S H E BOARD OF HEALTH Food/Kitchen � PER I D Septic System BUILDING INSPECTOR THISCERTIFIES THAT ............... .......... ....... ............ .......................................... ....................... Foundation has permission to erect.. . ......... buildin on ...�Y ............. Rough tobe occupied as ........ .. ... 0............................................................................................................................... Chimney provided that the person accept! 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 Inspect! , Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough 1...:11. . .. ........................................ Service LDING INSPECTOR ` Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final 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. Date. . NORT►, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUS� i This certifies that �. . . . . . . : . .!. . . . . has permission to perform . �f, . . .? . . L plumbing in the buildings of,�!1.- .. �!.- . 1 . . . . . at . . . . . . . . . . . . . North Andover, Mass. ��jj a Fee...��'?,.�Lic. No..4/.-��.s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,L PLUMBING INSPECTOR Check # 63 '15 MASSACHUSETTS UNIFORM APPLICA ION FOR PERMIT TO DO PLUMBING (Print or Type) �d� Mas Da Permit # J�� '✓� e Building Location Owner's Name Type of Occupancy Residential New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES �1 N N n O Z r O W 'o (A F- J W X J N �' V Q 4i ? W (IS n Z vi Q rt Cr z ~ = G Z Z d L 1 ow W N X ¢ ~ W Xa W H H W a vi o J N a J z o W v a z 3 z a x x ' ° O ~ ZCc Z W LL x a a o a -j a — ¢ a Q o U rl 3 x J m vi o a J 3 = i- W LL u M a a 3ir aai rtf N rd rd SUB-BSMT. BASEMENT VI IST FLOOR 2NO FLOOR 3RD FLOOR 4 4TH FLOOR STN FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name Heritage Htg. &Plg. Co. Inc. Check one: Certificate Address_ 35 Pleasant Street [X Corporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone 781 —438-7776 (1 Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I 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 coverage by checking the appropriate box. A liability Insurance policy IN 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 El 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1 2 of the General Laws. BY - Title Sighature of icens-ej umber City/Town Type of License:Master[g Journeyman p a APPROVED—FOFF—ICE—USE ONL ) License Number 8322 U. r /1/2"'Watts 9D bfp on water line to steam boile BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER d PERMIT GRANTED DATE 19 PLUMBING INSPECTOR L?y • s i Date.../ ! Q ...... AORTH TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING AcmU This certifies that ...A' .r.:�!... has permission to perform ........... - G�' %�1 �1,.1, ................ wiring in the building of..,��/ ,.Y�/ Gtj.//,�............................. �7 �j y Lf jL .at..........�.....1..��1�.-.:............�........L..f..................�..J.....�, -North Andover,Mass. / Fee.';!. .... Lic.No.<.- 0W ...... :Y....�/('/ j1�//,i11. .1 1 ELECTRICAL INSPECi'OR � `C, heck # 554 � USC Unry 4fJR rrnu-P.rr( C� ,•irr, 7 1'rrlrui',go t Occupancy ccupancy) ntF4ee Checyed30ARn Cf CIRC PREVENTION FREGULATi ,Na Rev, it/99 APPLICATION FOR PERMIT TO P R FO R ELECTRICAL Q R 11t1 s(wk 10 tic ricilormcd in accorJalicc I.1111 a �•t.,s; (P I rlS(' PH/NT W INK Olt' TYI•',1;.! .0 IrVI . 1 i11. 77OrV �I'irsclls El"Irical Cn,lc(1 11 C),5z7 CNIR Q 00 City or To{v){ of: ) 1)alc:� -,C_�'� 05 DY 1111s a li(olion the - �.... /1-t ve To /I)e hi. ,, `�" -------- Pp ur!dcrsi•rllc+l ivrs r!otl�c of h!c `� "-- j aC14r pJ f.y"ir rs c r ,cr i ir.ntle�ll Il, peri trot the elcct)uaf% oik' elaly. l..ocaflu!1 (Street .0 1NurrrDcr) described b Owner or Tenant Owner's ru{iress r--�...�,. .�-_- _ ------._.__ ----- Telep tolle No, ls U►is permit It{ co►►lLill(tiI,, {Yltll { VIr1lJlnu 1>cnnii' 1'csll ^i 1'url,usc 1)f 11uitJillk _- _ --- �J !YO _ {�11t1 f: rlksFlrn})riafc flox) ^ -------____...._ _ _ Ulilil)•Authoriz"Ovii INu. _... Exisfir►�Set s-ice _ t11t1 ,s -`• -� 1rulls 01 c,llcaO El U11d,urti ,`lcrr 4_cLr it - No. of Meters . - mpi 1 1 ails I art? , -----.- Tj _ Number of Feeders 'lid A.r)tpacity Nn• of.Nfefers. I,ocatiull ar1J Nature of f'r 1)os c(1 E)c(1 r i c a I Work: -----------_ , I\'d. of Recessed f'IYtill•ei f �� - - 1 r►.of Vfc unlrc,!(�v!/r� lr,r CNprp!Jt'irCt. i1n.of Ccil.-Susi. (l' t(1(11c) f arts `- _ --_ _ No. of Lighting Outlets ._. �ransfarlalcrs "dotal No. of llul '1'ui!s - K.Vr�, -- _- Geuc.rafors h,V7A I\'A. Of l✓i lltitlp f�.l)oy(� . f; ` n 1.1'tlllYs _ .Sttinintillo Pool o Ali -7 0. 0 1I11Nrgeltcy l�Fltilt�" No. of Receptacle Outlets �tIJ•_ ❑ rnJ_ _i•1 utter Ur►its o. No.-of Oil Burners � F 1� -- - - _ A1..A.R111S No- of Zoites INO. of Switches -�- ___._ o .,as Ilurners INTO- No. Ue ct iara and '- IN'o. of Ran4es . 'fbral �'� _ Inifiatin�Dcyicrrs _._...- _. _.._. No. of Air CouJ. - ;Cogs , of AlMing Derives \'o. of Waste Disposers tJr�t Yui1,p ,N(sn,ber foes 1�1V --------.--i Totals: iVn.ti�.�cj{-CAntafrled-"`-`�"' - _ - -- --- _ efectin�lJ,#terlino N(l• of Dis1r{nasllr.rs — --- -- Aevices Spacrl,1rrl ?leaiit+g 1<1V Local (]R,ltiicipIl 01F►er INo• of Dryers )1calinR Apnliaticls �ullnCrt1011 Nu. of-1V1ter� '""`"•�""""- t t ,--_.___.__.'\_a'-of_----.._____._._.____.__._1<1Y Security fffatcrs rC ,1 \I�. al --- ^Pf[3cyiccS QfEquiYalent 11a11:1sts - flat^ 11'iriuG: -_ Ultfro►nassa a f3alhtubs ~_- No,of Dc%,iccs ot•£ uir�fel:t Na. of Motors 7'ofal �i� Feectin)rnlruRcation' 1 O�I'fFft __--__-•- -- _ - +to,of Devices or lwquis afent ti. tNSf11L11siC'F ( 0\,Eft.1Cf : .frtntJr ndrlilionnl rlalnr , 1 "--�- 1 frl4tirgp o�as rcr),rired br rbe Intpecror of Wires, 1bilit s waived by the owner, no permit for the performance of clecrrical work play issue unless v the licensee proviJcs P100(of liability insuraltcc ioclu(91119 "con-pleled opera tion"covcra 'e unilersigned cerlififs that such cover ,c is in force, a,d 11as erltiUited prnoFcf same la raflipermit issuing illice. � or its suhstantiaf fqui�'alet)l. Tf1c �•C•�f-IEGK ONE, lNYS1 Rj�N(°f nJ ,FY grE,�r �ukltrc, poNa O _)(>lflt.R � (SI>ecify ) �slitttaled Vfluc ()f Eirclricaf 1Vntk: --_.. _ Wolk to sotiIVhen rr aired b n►I,nicipaJ pol;c) ) (E\P'rallon D.)tc) /9 �J lnspec I01's to be rqumt:d il! accl•rd._MCC �,itll 111FC Rule 10, snd upon c jr- - r, !rl rho•lrnul i nrr,l pr-rrnlrr�,s u , ',Ir rh,,r r?I ;,. ! p Ion. l/' J 1 wo" his nl,lrll(•ariu„ is Mee am/carrrplr.I(. ►.irintcc; Zt, . L.1C. r\U.:Address. ,�'rrIJrC . rnun .r l,r+c — t,)C. !�(7.: IlPAO/- y�'-L_ (' ` �g �� ! )3us. Tcl. r\o.:.. 1V.11t"C 1 1 ant a,�are ih:1( the i.icrnsr:• ,�,, • r1f1,TO. No.: tft7l,ir(J by la., r u�' /rune rhe li�hi(ity irs;uc,in;c cn,era` f3Y my 51alta(n,c be Ic,r,, I lu,ch) ,::,;,:• Ihls rrlturrrr i u1 ! alll(lie (r heck Rnc c nornrally r"lien/�1�cut • .l. r's _- -- ------ �'J.'R, rT-,r s