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HomeMy WebLinkAboutMiscellaneous - 34 CHURCH STREET 4/30/2018 (2)NORTH ANDOVER HISTORICAL COMMISSION Mr. Gerald Brown, Building Inspector December 22, 2008 Town of North Andover 1600 Osgood Street North Andover, MA 01845 Dear Mr. Brown, The North Andover Historical Commission received a request to put an 8" x 10" shed on a property located at 34 Church Street. The owner of the property contacted the Commission as that address is in the newly formed Neighborhood Conservation District, and the owner thought she might need a certificate of approval from the Commission. According to the NCD By -Law, this individual does not need a certificate, as the by-law states that "Accessory buildings of less than 100 square feet of floor area are exempt from review". If you have questions or need further clarification, please call me at 978-6835536. Sincerely, Kathleen Szyska, President North Andover Historical Commission Post Office Box 454, North Andover, MA 01845 S � 9 Jan 13 06 08:14a Joel winslow 1-603-362-9733 P.1 04e LLnmmnnweultlj of Ramialc4metto Office Uzc Oniv Department of Public Sajky Permit No. �,y 2— BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00Occupancy h fee Checked` N90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perwrinert in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 13-b City or Town of 1VVr,1q 41i4 ,,IN To the Inspector of Wires: The undersigned applies for a pPimit to perform the electrical work described below. Location (Street & Numher) •./_.f-L�_ _✓.... —___— Owner or Tenant �� -LF-NA) Owner's Address jV ( ID ✓ —Ate 01 V-, _ L✓ Is this permit in conjunction with a building permit: Yes L_1 No Purpose of Building Existing Service _ Amps _ 1 Volts New Service Number of Feeders and Ampacity Amps / Volts Location and Nature of Proposed Electrical Work I (Check Appropriate Box) Aility Authorization No. Overhead( Undgrd ❑ No. of Meters Overhead U Undgrd ❑ No. of Meters OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O NO 0 ! have submitted valid proof of same to this office. 5 0 NO O If you have check ES, 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 Inspection Date. Requested: Rough Signed under the penalties of perjury: Final �- FIRM NAME �L A 1 tw _LIC. NO. g:5709 Licensee �lD��� Signature �. �` j• "- _ LIC. N035 41 'ri AE.- � r Address �,/fir 1LqL -_ V M — • l Bus. Tel. No..._._292 S- :M40 �r� 039/) Alt, Tel. No. -W3. OWNER'S INSURANCE WAIVER: t am aware that the Licensee does not have ;he 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) Jia Telephone No._ _PERMIT FEE 5 _ (Signature of Owner or Agent) . TOTAL No. of Lighting Outlets No. of Hol Tubs No. of Transformers KVA Above oveNo. EI No. of Lighting Fixtures Swimming Pool gind. ❑ grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and 'total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices Heat I otal Mal No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices No. of Dishwashers Space/Area Healing KW Municipal Connection ❑Other No. of Dryers Heatin Devices KW Local❑' No. n No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wirin No. Hydro Massage Tubs No. of Motors Total 11P OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O NO 0 ! have submitted valid proof of same to this office. 5 0 NO O If you have check ES, 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 Inspection Date. Requested: Rough Signed under the penalties of perjury: Final �- FIRM NAME �L A 1 tw _LIC. NO. g:5709 Licensee �lD��� Signature �. �` j• "- _ LIC. N035 41 'ri AE.- � r Address �,/fir 1LqL -_ V M — • l Bus. Tel. No..._._292 S- :M40 �r� 039/) Alt, Tel. No. -W3. OWNER'S INSURANCE WAIVER: t am aware that the Licensee does not have ;he 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) Jia Telephone No._ _PERMIT FEE 5 _ (Signature of Owner or Agent) NORTH ANDOVER HISTORICAL COMMISSION Mr. Gerald Brown, Building Inspector December 22, 2008 Town of North Andover 1600 Osgood Street North Andover, MA 01845 Dear Mr. Brown, The North Andover Historical Commission -received a request to put an 8" x 10" shed on a property located a(34 Church Street.) The owner of the property contacted the Commission as that address is in the newly formed Neighborhood Conservation District, and the owner thought she might need a certificate of approval from the Commission. According to the NCD By -Law, this individual does not need a certificate, as the by-law states that "Accessory buildings of less than 100 square feet of floor area are exempt from review". If you have questions or need further clarification, please call me at 978-6835536. Sincerely, ka ,Fc Kathleen Szyska, President North Andover Historical Commission Post Office Box 454, North Andover, MA 01845 Location ? 34 ce- val c -, sT^ No. Date NORTH TOWN OF NORTH ANDOVER Of"ao ,a,�•C JL ►° 9 + ; Certificate Occupancy $ ; of SACHUSEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 0- 0 r Check # a li I� '} Building Inspector v O i ► s}, F• ♦ss���t CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 528 2/28/06 Date: June 26, 2006 THIS CERTIFIES THAT THE BUILDING LOCATED ON 34 Church St MAY BE OCCUPIED AS Apartment Renovation IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: S J Glenn Acciard 34 Cliurch Street e� c sl u .G_ o m G Gts O N O :� C� •dam ; dG to eo O C :t C O. � Ea � C CD ... pis y uCi E� 0 0 -- a Nmm • cm o m 3 c f m CA � c ea y O 2 rLC.2 ` �G O Q �w O �O �Z eco QC F- = O Ot 03 F- h m2~ coo c cc 4D g _D is c ml I.- M AD O G — 46 LU •� vmv� cimCO2 d O.- O Z � Z&__.aC= F— Z 0- CL Ma m • N .15L N ti G ca O m cm C m 0 cm G �C N CD t 0 Z O 0 W a n 0 P v7J f-� r0 v a� O co O Z CLC O y C c cm ca y O O 'E m m a�CD CD 3.0 CD L ca d �Q c O C Q d O tCD ce Z CD C.3 Na O C — 'C C y 0 A � 0 " GL cn b x z :3 - G LL �i U ti GG Li. w v_ C50oo CL C x S c� w z p O C 1 cn cn u .G_ o m G Gts O N O :� C� •dam ; dG to eo O C :t C O. � Ea � C CD ... pis y uCi E� 0 0 -- a Nmm • cm o m 3 c f m CA � c ea y O 2 rLC.2 ` �G O Q �w O �O �Z eco QC F- = O Ot 03 F- h m2~ coo c cc 4D g _D is c ml I.- M AD O G — 46 LU •� vmv� cimCO2 d O.- O Z � Z&__.aC= F— Z 0- CL Ma m • N .15L N ti G ca O m cm C m 0 cm G �C N CD t 0 Z O 0 W a n 0 P v7J f-� r0 v a� O co O Z CLC O y C c cm ca y O O 'E m m a�CD CD 3.0 CD L ca d �Q c O C Q d O tCD ce Z CD C.3 Na O C — 'C C y 0 Gerald A. Brown Inspector of Buildings TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 3aA Telephone (978) 688-9545 Fax (978)688-9542 AFFIDAVIT FOR FINAL COST OF CONSTRUCTION In accordance with the provisions o the Massachusetts State Building Code, Article 1, Section 110.4 and 114.2, the total estimated cost of the construction including all related construction costs* of the building located at32A Church Street, North Andover, MA 01845 amounts to it 21,500.00 I, Glenn W. Acciard ,being the,person referred to as the owner identified below, do solemnly swear that the statements made herein are strictly true and correct and made in good faith. *Related construction costs included all work done with or concurrently with the work contemplated by the Building Permit including demolition, plumbing, heating; electrical, air conditioning, painting, carpentry, landscaping, site improvement, etc. Furnishings and portable equipn are no art of the total construction costs. 7-11 1. if COMMONWEALTH OF MASSACHUSETTS Essex S.S.June 23 20 006 Then personally appeared the able named Glenn W. Acciard Made an oath that the above statement is true. EU EN M. KELLEHER " NOTARY PUSUC COMMOhYW TH C MASSACHUSETTS W Com XP= Feb. 25, 2011 OFFICIAL USE: Signature of len M."Kellehek Notary Public Final Cost: Original Estimate cost of gene'r�l work:----�-- A ---� Cost Difference: - Additional Fee Required:-------�----- TO AMEND FEE UNDER PERMIT NO.:--�---�- ��--------- TM -� Inspectional services Department 2005 F:Tmalcostaff'idavidonn Strict code enforcement makes the town safer Before buying, renting, leasing check zoning S 7'', 3 Date 6. -. 1`.5..� . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform plumbing in the buildings of ............... at``?�Ll '. . 7 ,North Andover, Mass. Fe......Lic. No/ ....... .............................. PLUMBING INSPECTOR 06/15/98 14:58 30, 00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATN FOR PERMIT TO DO PLUMBING .ype or print) NORTH ANDOVER, MASSACHUSETTS Duilding Locations Owner's Name New F-1 Renovation ® Replacement Date 6 >)42 ¢ – Permit # Amount Plans Submitted 1 1 (Print or type) Installing Company Check one: Certificate ❑ Corp. Address KU r'C 'e U Partner. Akt�C L Business Telephone Firm/Co. •t Name of Licensed Plumber: IC I~Z� ZD Insurance Coverage: Indicate_ the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been mdde aware that the licensee of this application does not have any one of the above three insurance Signature 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 installatio perfo der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett luT1 a hapter 142 of the General Laws. By: signature o ice s m Der - Type of Plumbing License Titlet'�� LZ6 M City/Town icen er aster Journeyman ❑ APPROVED (OFFICE USE ONLY • s � • ------------------�-.---■ • `9 9 I ,------------------------■ 11 • mmmmmnmmmmmmmmmmmmmmmm ME (Print or type) Installing Company Check one: Certificate ❑ Corp. Address KU r'C 'e U Partner. Akt�C L Business Telephone Firm/Co. •t Name of Licensed Plumber: IC I~Z� ZD Insurance Coverage: Indicate_ the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been mdde aware that the licensee of this application does not have any one of the above three insurance Signature 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 installatio perfo der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett luT1 a hapter 142 of the General Laws. By: signature o ice s m Der - Type of Plumbing License Titlet'�� LZ6 M City/Town icen er aster Journeyman ❑ APPROVED (OFFICE USE ONLY /xI/K Date..................... %` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �SSACMUSE Y'� This certifies that has permission for gas installatiofi .�! / It/2 in the buildings of�................ . at..)... c ... !! . !........ ! ....... North Andover, Mass. Fee...:.'. Lic. No.. ... !. .......................... GAS INSPECTOR ' Check # k MASSACHUSETTS UNIFORM APPLICATION OOR PERMIT TO DO GASFITTING (Print or Type) G N Q 21 H A k)QP V E ►�(- , Mass. Date1 8 06S Permit # Building Location_ - i (Fl l t icC_.N 1 / Owner's Name KE u N � i H iE v )JO r2Ct T H A 0 'x /r- K- /14A Type of Occupancy_ kCS10 ,,1714 U New E] Renovation E] R plaJy ement Plans Submitted: Yes❑ No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone .687-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # 17 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability ns r❑ ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked ve , please indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type of indemnity ❑ Bond O 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 ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in plication are true and aocu%te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application wil n mplianoe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene - s. (/ i BY Tof License: 5Of Signature of LicensedHumber or Gas Title Gasritter Master license Number Cit /Town Journeyman O IC S_O 1 Y • Y • moon MEMNON Omni own Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone .687-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # 17 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability ns r❑ ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked ve , please indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type of indemnity ❑ Bond O 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 ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in plication are true and aocu%te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application wil n mplianoe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene - s. (/ i BY Tof License: 5Of Signature of LicensedHumber or Gas Title Gasritter Master license Number Cit /Town Journeyman O IC S_O z' 0 v w CL N z N N w cr 0 O n. d z- t- lL N J p z � O N r a w- � - U � •v o a z 0 z cc Ir 4 0 0 IL LL j z b O O 9L 0 .� w ula a m v J t' CL .� CL Q w w � a U z N w z (NI I - w x N z .. I Q w m a O Y d The Commonwealth, .Massachusetts. Nratt b. tr Department o blie Safety Occu�uncy b Fee Checked BOARD OF FIRE PREVE N REGULATIONS S27 CMR 12:0 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Work to be -performed In accordance with the Massachusens Electrkal Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 9 City or Town of lje)�6 %�/l tU�/y� To the Inspe r o wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address =-? S, Is this permit in conjunction// with a building permit: Yes'�No 11 (Check Appropriate Box) Purpose of Building D w r A ci E, Utility Authorization NO. — Existing Service G (5 0 Amps -1/ , 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 Electzical Work �L✓� 2 � , t /, ,� �,J S 7' 0 ✓i' 4 C& No. of Lighting Outlets / No. of Hot Tubs No. of Transformers Total IN A No. of Lighting Fixtures SwimmingAbove In - Pool grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets c� S No. of Oil Burners No. of Emergency Lighting Units No. of Switch Outlets 'Battery No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal ❑Other Connection No. of Ranges i tal No. of Air Cond. To No. of Disposals No. of Heats TTtal ToKW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP .. OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a currentLi alit Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES eNO L] I have submitted valid proof of same to this. office. YES C�r NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCEBOND ❑ OTHER ❑ (Please Specify) COO-4lco/Ccr� piration ate Estimated Value of Elect ical Work $ JSf�1� Work to Start Inspection Date Requested: Rough Final Signed under the pinalties of perjury: /- -� FIRM NAME _ l L) SC,�j }�/� / l � C� C' �7i2Gil!� G� �i LIC. N0. License Address `f (J L J>CX 5 v t7ly. Tel. Alt -- - Alt. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts GeneralwsTa , and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent INSPECTION RECORD Date Notes-- Remarks Ins per '.,o ,q� No Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................. ............................ has permission to perform ............. ........ .......................................... wiring in the building/o f ................................................... ...... 71 at................................... .. r, ass. �/ Fee ... Lic. No .............. ..................... .......... I t�n MICALI �sv r - R 7 r WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................L -=' �- *� ................................... ............................... has permission to perform-.:.'. ' _ - ............................................................................ wiring in the building of......... `! �` ` ". .....:.................:...................................................... at ............/ ................................. l............................ , North Andover, Mass. Fee..7a.. .:/..... Lic. Nd'' ..... / .............. J `......./... �... ELECTRICAL INSPEC'�OR�' . Check # Z % Lyy • r r I Jan 13 06 08:14a joel winslow 1-603-362-9733 P:1 011e Tommonwealtli of Rassa0usetto Dffrce Use Oniv Departntera of Public Sajitg Permit No. 1075 2._ BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Fee Checked 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Ntassachusetis Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date -13 City or Town of � hape! To the Inspector of Wires: The undersigned applies for a peprmiit[to p/erfor'm the electricall^work described below. Location (Street & Numbe1r)�� / t. _j� ft ii=g1,.� _ 6T_. --__—. Owner or Tenant WAW [��L1CC/�j!�-�/L^_V �y� -- Owner's Address 1 f rmao "d' W, ' Is this permit in conjunction with a building permit: Yes No Purpose of Building Existing Service _ Amps _ / volts New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work (Check Appropriate Sox) Aility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusties General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO fl ! have submitted valid proof of same to this office. 5 ❑ NO 0 If you have check ES, 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 Inspection Date Requested: Rough Signed under the penalties of perjury: Final FIRM NAME Al—r-- t' ; W —LIC. NO. Licensee ae� # Signature rr% '� LIC. NO,��. ^� Address V , 1' 4 1V4 %iett, _ : Bus. Tel. No. ! 7S1F Se -'2Y7 �} Y7 03R/) All. Tel. No. 603' A'Z- %5_5 .OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have ;he insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my sib:tature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. _ PERMIT FEE $ V � (Signature of Owner or Agent) - TOTAL No. of Lighting Outlets No. of Hut Tubs No. of Transformers KVA No. of Lighting Fixtures Above I n - SwimmingPool md. ❑ rnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Bumers FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices. No. of Self Contained Detection/Sounding Devices Municipal Local❑ Connection ❑Other No. of Disposals Heat lotal lotal No. of Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heatin Devices KW No. o No. ot Low Voltage No. of Water Heaters KW signs Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusties General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 0 NO fl ! have submitted valid proof of same to this office. 5 ❑ NO 0 If you have check ES, 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 Inspection Date Requested: Rough Signed under the penalties of perjury: Final FIRM NAME Al—r-- t' ; W —LIC. NO. Licensee ae� # Signature rr% '� LIC. NO,��. ^� Address V , 1' 4 1V4 %iett, _ : Bus. Tel. No. ! 7S1F Se -'2Y7 �} Y7 03R/) All. Tel. No. 603' A'Z- %5_5 .OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have ;he insurance coverage or its substantial equivalent as required by Massachusetts .General Laws, and that my sib:tature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. _ PERMIT FEE $ V � (Signature of Owner or Agent)