HomeMy WebLinkAboutMiscellaneous - 32 FRANCIS STREET 4/30/2018 32 FRANCIS STREET
210/014.0000.0
Date. .��� �. ?... .....
HORTM
,e,tiQL
TOWN OF NORT-WANDOVER
FO � P
g PERMIT Fbfl"GAS INSTALLATION
.{ SACHUSES
This certifies that . . . .RA, / .&/- !: .`. . . . . . . • • • •
has permission for gas installation 5'.`.: . • �•
in the buildings of
at .?!. )//!. . :-. North Andover, Mass.
Fee. . . Lic. No.. .?7.`� ? . . . . . .��. . !J:!`'d`
GAS INSPECTOR "
Check#
I
. . It
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
tiDF—fN ANOOVESIL , Mass. Date // 6 7 Permit# L
Building Location-3/y 31A;33.33A /=RArJeiS ST Owner's Name A10kT1-1 AAX,WE-,k- yrSC,, ,4t, /
AIDP?rN A0Wjc-e,1, 14A Type of OccupancylCtS/r'1ErJ 1R l uA)IT_S
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No❑
N W .
Y W N u o
N N U Z ¢ �.
W W rr O O O N = 5 �2
J N V m ~ x '�
z O u ~ < Cr Z O O } W of 4
� m y H Uj w o o a o H ��
W Q _ t- � ar
N a W Z V W N W < OC OW 1A
tl f, z J f' x cc
W a tl W W I-~ W V H a
Z' Q W J m z O Z CW'. O ��yy S
¢ '.= O d Y LL a 3 C tl j v ¢ y a a F O
SUB—BSMT.
BASEMENT
1ST FLOOR
y 2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name BAY STATE GAS COMPANY Check one: Certificate #
Address 55 MARSTON STREET X7 Corporation 1862
LAWRENCE, MA 01840 ❑ Partnership
Business Telephone q 78-68,7-1105 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery �.
INSURANCE COVERAGE:
I have aY usrrenntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked Les, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy X( 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
I hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and aecu�gte to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen s. (/
T of license:
Plumber Signature of cense Plumber or Gas
Title Gasfitter
Master License Number 374-5
City/Town Journeyman
APPPDWff O IC SE O
BELOW FOR OFFICE USE ONLY
FINAL, INSPECTION SKETCHES PROGRESS INSPECTION
FEE
N0.
APPLICATION FOR PERMIT TO ADO GASFITTING
r. NAME& TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER OR GASFITTER
LIG NO.
PERMIT GRANTED
DATE
GASINSPECTOR
Commerce InsurancesM
The Commerce Insurance CcmpanysM
C1c Citation Insurance CcmpanysM
SM
Members of The Commerce Group,Inc.-
CLAIMS DEPT. 11 Gore Road,Webster,Massachusetts 01570 (508)949-1500
www.Commerceinsurance.com
August 16, 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: JAMES F ACKROYD/CLAUDETTE ACKROYD
Property Address: 32 FRANCIS ST
Policy#: ZW7257
Date of Loss: 06/27/2013
Filek HJKC93-YTNX52
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.
LISA LEAHY Telephone: (508)949-1500 Ext: 15846
Claim Representative I,Property Toll Free: 1-800-221-1605,Ext: 15846
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 16, 2013
Veh hit house
CcI11mCirc Ccmpanies ....COME GROW wITi us
CIC 254 (Rev.4/95) MAIL 788
Location
No. DateOf
N°RT" TOWN OF NORTH ANDOVER
" Certificate of Occupancy $
* = " Building/Frame Permit Fee $
3.? CHUSE�� Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
,� ,•. rajO,.Tonnection Fee $
��� �- =; ._, - �•'' TOTAL '
Building Inspector
Div. Public Works
PER11IT NO. / l '/ APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. 1c, PAGE 1
MAP 410.1 ` I LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK -'PAGE —
ZONE � SUB DIV. LOT NO.
LOCATION 3 'S PURPOSE OF BUILDING
OWNER'S NAME -•S /R�j iv ,Y► /-S�'O '�U C NO. OF STORIES w SIZE
OWNER'S ADDRESS �j �n�y vC^ J BASEMENT OR SLAB
w- 4� SIZE OF FLOOR TIMBERS IST2� / 2ND 3RD
ARCHITECT'S NAME( i-(
BUILDER'S NAME )'yt•/ G� / �' n SPAN / -----
DISTANCE TO NEAREST BUILDING 6w, 'i DIMENSIONS� OF SILLS --_
DISTANCE FROM STREET POSTS Lynx
DISTANCE FROM LOT LINES-SIDES feo/ REAR GIRDERS
AREA OF LOT /'V FRONTAGE HEIGHT OF FOUNDATION %/1 / THICKNESS
IS BUILDING NEW SIZE OF FOOTING D/�S�w � X
IS BUILDING ADDITION `,�/� p�L /'f' ,•�,` /����!� MATERIAL OF CHIMNEY '\f/�/
IS BUILDING ALTERATION �(• CSL V� /*� IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE jam+ /�� IS BUILDING CONNECTED TO TOWN WATER /
BOARD OF APPEALS ACTION. IF ANY Y 2 IS BUILDING CONNECTED TO TOWN SEWER V1_1�
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST
PAGE 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER SQ. FT.
PAGE 2 FILL OUT SECTIONS I - 12 EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
I
PLANS MUST BE FILED AND APPROVE/DJ BY BUILDING INSPECTOR
ZNATE FILED
BOARD OF HEALTH
SIGNATURE OF OWNER OR AUTHORIZED AGENT
F E E
PLANNING BOARD
PERMIT GRANTED
,9 9/
BOARD OF SELECTMEN
r
OWNER TEL 0
CONTR.TEL 0
CONTR.LIC.N
BUILDING INSPECTOR
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION —I 8 INTERIOR FINISH
CONCRETE B I 2 13
CONCRETE BL K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER _
_ DRY WALL _
UNFIN
3 BASEMENT 11
AREA FULL FIN. BM TAREA _
'/. 1/2 1/. FIN. ATTIC AREA _
N_O B M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPS B 1 _-2 3
DROP SIDING CONCRETE I_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDVJ D _
ASBESTOS SIDING COMtACN
VERT. SIDING ASPH. TILE �{I_
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIORI—_( POOR
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE I HIP BATH (3 FIX)FIX)
GAMBRELMANSARD TOILET RM. (2 FIX.) _
FLAT-11SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK _
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING I 11 HEATING
WOOD JOIST PIPELESS FURNArE
_ FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
IL
O
B'M'T 2nd _ ELECTRIC
1st 13rd NO HEATING EH�l
1
v
3 r
t
".tw. ..
! l,l TIT f .' v •' '�
Y�rirYb�r+cvrr.i•..rr.ai-rinrr.,.•.rw.'..,....trr-.. - - ".J.A.r._....._..._.r......•.... ._.�. ..
DEPARTMENT OF PUBLIC SAFETY
$ COMMONWEALTH 1010 COMMONWEALTH AVE.
s
:r{ OF BOSTON,MASS.02215 '
77
MASSACHUSETTS
! ti
LICENSE
EXPIRATION DATE C Q 4 J T R• S U P F"V I S U P I
07/31/1993
6 EFFECTIVE DATE LIC-NO. S
RESTRICTIONS o 0 8 101 l
01 /1 9)u 054204
NONE �
n �
mJowi F LECHLEITEL
7 Gt)UUkIN PhAD
S5 # 501-68-2196 GLOUCFST R ?A 01930
PHOTO(BLASTING OPR ONLY( FEE: _
0.CU
• HEIGHT; NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY
•, STAMPED OR SIGNATURE OF THE COMMISSIONER
DOB:
10/ 1911954 0 0
THIS DOCUMENT MUST BE SIGNATURE OF LICENSEE
' CARRIED ON THE PERSON OF • •
.�•1 THE HOLDER WHEN ENGAG- . MMISSIONER '
JI{ OTHERS�:IGHT THUMB PRINT ED IN THIS OCCUPATIONZOOM2.871429
t
��"�/i.i w S .+�..a..� .i�.� � �� ..:i 1 .,�� '�;i ' � _ ✓7 i y.i ... • .. .[ 16+. ��; r. � � y.�i�1-�� pp '�fj c�— - .
V7 SWIM
yr �•it ' 7J
•� � a a 1MITiC n� Ew� �� MVV � 1 9
V/
ASR PPERMIT LD ay
- SS
BOARD OF HEALTH
THIS CERTIFIES THAT...I �o
..... .. .................. . .......... ....... ......................................
BUILDING INSPECTOR
haspermission to erect ('004'*40 �........ on ��.. ..��..................�.............. Rough
to be occupied aA7".T'A1jjr .dvA.!rct.cle. Chimney
Final
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in
PLUMBING INSPECTOR
this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough
Buildings in the Town of North Andover. Final
VIOLATION of the Zoning or Building Regulations Voids this Permit.
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST TION STARTS Rough
Service
Final
........ . .. .............. ..... . . . . ..
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Final
Display in a Conspicuous Place on the Premises
Do Not Remove Burner FIRE DEPT.
No Lathing to Be. Done Until Inspected and Approved by Smoke Det.
Building Inspector
Location
No. Date
�0"T" 41 TOWN OF NORTH ANDOVER
3?o•4t`•D •, 0
♦ � L
zialkidkp Certificate of Occupancy $
Building/Frame Permit Fee $
'rl b+,no'•,
CHU Foundation Permit Fee W
Other Permit Fee $
Sewer Connection Fee $
Water Oonnection Fee $
TOTAL $
Building Inspector
Div. Public Works
t
E X.IS1 fNG
GARAGE
DECK LEVEL EXISTING !
W,'HOUSE FLOOR HOUSE
C
�/X7 LEVEL e
I � .
432
ZX6 o
INTEGRATE RAMP EXISTING SHRUBBERY
%',ASPHALT I TO REMAIN
it i
I CL
ALL FRAMING LL
A } ¢ JOISTS, DECKINC
T POSTS SHALL BI
o
7�eC a ! N PRESSURED TRE
Q I I SOUTHERN' YELLt
¢ I
( �NC►1U1'Lj
1 � I
ti
w I 2 X 6 5 ;
-EXISTINGLAID
n
.FLAT I
DRIVEWAY-1 I i+ � + �'• II ii �._ __... ACROSS
i
_ JOISTS
-
+12
61 i
LEVEL
.—+-
��
Ii
4.. 0" 1 i 4.-p„
CoNG. I
PLAN OF RAMP PIERS
To FIRM SE
F'o,t,. I s ►�.,
NOTES
16 ALL WORK TO BE DONE SHALL BE
BLDG. CODE AND REGULATIONS OF
2. ALL MEASUREMENTS ARE APPROX
BY THE CONTRACTOR.
3. THE CONTRACTOR SHALL PROVIDE
EXISTING ! 4. INSPECTION BY THE ARCHITECT SF
HOUSE
CONTRACTOR TO FURNISH SATISFA,
co WORKMANSHIP OR TO COMPLETE
EL a INFERRED TO IN THIS DRAWING.
5. ALL EXISTING CONDITIONS AND/OR
2 DISTURBED DURING CONSTRUCTION
OR REPL..CED TO MATCH EXISTING
II
6. ALL CONCRETE SHALL BE 4,000 P�
ACCORDANCE WITH ACI, AND MAD
7. ALL NA1014IG SHALL BE iN ACCORD
PRACTICE. ALL NAILS, SPIKES, AM
i
S. RAIL STOCK ;AND CUT EDGES SHAI
EXISTING SHRUBBERY OF CUPRINOLI WOOD PRESERVATIVI
TO REMAIN 9. CONTRACTOR SHALL CONSTRUCT
STEPS:AND PLATFORM. REMOVE
10. CONTRACTOR SHALL PROVIDE
CL t— ALL FRAMING LUFr�pER, AT FOOT OF RAMP AS REQUIR
¢_ JOISTS, DECKING okND
o POSTS SHALL BE :K S
N PRESSURED TREATED
SOUTHERN' YELLOY' PIt4E
4, 0, —
I
4-
2 X 6 5
LAID ++
FLAT t . 1 314
_ . . G
ACROSS
G9 RAIL
i --- — JOISTS iy STOC
! CHAN
ol
BOLT POSTS 2 x 4
2 X 6 — _ — THRU FRAMING w/ 2
-- . 2-2 x 6's LAG
STEEL ANCHORS EXIST
SCBE
GRADE
IMP PI ERs
To F.R►�1 SECTION THRU RAMP 112' _ �'-o•
NOTES 4 0
1, ALL WORK TO BE DONE SHALL BE SUBJECT TO THE MASS. STATE Q `
BLDG. CODE AND REGULATIONS OF THE MASS. REHAB. COMM. x
2. ALL MEASUREMENTS ARE APPROXIMATE AND ARE TO BE VERIFIED J Z
BY THE CONTRACTOR. Uo
3
3. THE CONTRACTOR SHALL PROVIDE ALL PEFFIM!TS. N
4. INSPECTION BY THE ARCHITECT SHALL IN NO WAY RELIEVE THE p U < .
CONTRACTOR TO FURNISH SATISFACTORY MATERIALS ORw
Q
WORKMANSHIP OR TO COMPLETE ALL WORK DISCRIEED OR x
It'FERRED TO IN THIS DRAWING. L)
p _
5. ALL EXISTING CONDITIONS AND/OR SURFACES WHICH ARE W�Q •
DISTURBED DURING CONSTRUCTION SHALL BE PATCHED, REPAIRED
OR REPLACED TO MATCH EXISTING AS REOUIRED. n
� u
6. ALL CONCRETE SHALL BE 4,000 PSI AND INSTALLED IN 1
ACCORDANCE WITH ACI, AND MADE IN ONE POURING. ° U
7. ALL NAILING SHALL- BE IN ACCORDANCE WITH BEST CONSTRUCTION
PRACTICE. ALL NAILS, SPIKES. AND BOLTS SHALL BE GALVANIZED. x U
8. RAIL STOCK ;AND CUT EDGES SHALL BE TREATED WITH 2 `
COATS
OF CUPR)NOL)WOOD PRESERVATIVE. a ° a o
0 0 �
9. CONTRACTOR SHALL CONSTRUCT DECK AND RAMP OVER EXISTING E 3
STEPS.AND PLATFORM. REMOVE EXISTING HANDRAILS. u°
10. CONTRACTOR SHALL PROVIDE NEW ASPHALT OR CONCRETE `"" -`--
AT FOOT OF RAMP AS REQUIRED.
Q
pU)O cr ¢ Q
UJ
O
!E m O
zZ
<
zQ =
4' 0.
Q N O
is Z
N
! I I
i
RAILj' -;i
iv io STOCK lr! CANTED _
CHAMFER TOP
" W i
i
BOLT POSTS 2 x 4 ! ; ` z !
2 X A6 - - THRU FRAMING w/ 2 -1 /4• �, ` p
2-2 x 6's LAG LL Q
SCREWS O
:EL ANCHORS EXIST '� x 4 z J
GRADE POSTS J
Jd uj r +
HANDRAIL L'"�-z•� `'�
N THRU RAMP 1/2• = V-0• DETAIL 3• = 1'-0• An
Location '3?—
No.
?No. ZC,n' S Date i q'
NORTH TOWN OF NORTH ANDOVER
?O: 0L
} a Certificate of Occupancy $
Building/Frame Permit Fee $
�1 b•�rae ���
SEs Foundation Permit Fee $
cMu
Other Permit Fee S(,k) $ cr
Sewer Connection Fee $
Water Connection Fee $
TOTAL �� $
t�
Building Inspector
J Div. Public WGI�s -
LED 16 _14,,�O
TOW N O F
N O R T H A N D O V E R
AIL
%� �� 'QA COCIIIC MC•v1CM V
DRATED PPS`
�SSAC HU'5
�`•'' '�. { DATE: k( NORTH ANDOVER, MASS .
PERMIT #� S I G N P E R M I T
THIS CERTIFIES THAT. - • - - - • • • - • • • • • • • • •% " " ' • ' • • '
has permission to erect . Zk?' . :5i�'..l • •�N U3%M•0•�� • • • • oto 1Z t1!1!�KCt� • , , , • ,
.f
this permit shall in every respect conform
provided that the person accepting
! to the terms of the application on file in this office , and to the provisions
of the Codes and By-Laws relating to the Sign Regulations in the Town of
North Andover .
VIOLATION of the Zoning or Sign Regulations , Section #6 , Voids this Permit .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Building Inspector
r
SIGN PERMIT APPLICATION
NORTH ANDOVER BUILDING DEPARTMENT
Division of Planning & Community Development
Date Filed:
1. Site Address = /U�J� �� j�h��2 - 09 (p C� i
2 . Owner-. S0h& PA Q�VV(I (Y)CnagL
63 . Applicant � 1 �Q , — Cnc,"
4 . Number of Signs Size of Sign(s )
S. Site of Proposed Sign(s) 3 F("T1Ct/o�;L
6 . Materials : 5i(4n .cA C (- (6p ,i
7 . How attached: (a) Against the wall ( )
(b) Roof ( )
(c) Ground ( )
(d) Other bh;n 4Vy .A ,n )j (✓)
8 . Illumination: (a) Not illuminated ( )
(b) Inter ally illuminated ( )
(c) Illuminated from separate service ( )
9 . Proposed Colors : Background �l
Lettering CV_
Border \CtiCV-
10. Will sign overhang any public road or walkway: Yes ( ) No ( ✓S
11 . If Yes , Name of Agency who will provide liability insurance :
12 . Attachments :
( ) -;Photographs of building
( ) Material sample
( ) Color samples
( � ) Site or Plot Plan (Required for all free-standing
signs)
( ✓ ) -;Drawings of proposed sign
( ,/ ) Other, specify
13 . Is Board of Appeals decision required? Yes ( ) No (✓�)
Signature o Applica At �214Z NOV _21994.
1988
• .. � -r � i i. e `.� .ter•..,+rr y, � `
a
f3c w P\�AA \
LQIPI
x
r.'
u ,
I _
� � a
U t
Date..... / ��
P
e°ao RT 1
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�O•�no ��'(y
;,SS^CMUSES
This certifies that Il...l..........f..=.. �' C
................. . ..............................
has permission to perform ............�.:� � ��
Wring in the building of..... .................................................
at-...71. .x. ..........r .. .. NorthAndover,Mass
i
Fee... Lic.No.��. ......... �, c .s
ELECTRICAL IN ECTOR
Check #
lay ._ •;
Commonwealth of Massachusetts Official Use Only _
Department of Fire Services Permit No. Q�
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 QjoMR 12.00
(PLEASE PRINT IN INK ORE AL�INFO ATION) Date:
City or Town of: /7� To the Inspector of fres:
By this application the undersigned Ives na of his or her intention to form the electrical work described below.
Location(Street&Num e124
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead LJ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Installation of Security system
Completion of the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool Above ❑ In-rnd. rnd. BatteryUnits
❑ o.o - cy ig ing
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.-oDetection n ndInitiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
s Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local E] Municipal El Other
V Connection
No.of Dryers Heating Appliances KW SecurityNo.of Devices or Equivalent�0
No.of Water KW No.of No.of Data Wiring:
Heaters ISigns Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total: H' Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: ViVaInspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify, under th ains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Secucity LIC.NO.: 15 J_J(`
Licensee: John S. Bassett Signature LIC.NO.: 1533C
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: 603 594 5928
Address: Alt.Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Lid,9hsee 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: $