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HomeMy WebLinkAboutMiscellaneous - 36 PERLEY ROAD 4/30/2018n �4 North Andover Board of Assessors Public Access NCRTf� Ott«eo .��4 Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 roperty Record Card Parcel ID :210/053.0-0014-0000.0 FY:2012 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO Click on Photo to Enlarge Location: 36 PERLEY ROAD Owner Name: GALLANT, RICHARD STEPHEN GALLANT, JR Owner Address: 36 PERLEY ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.11 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1653 soft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 274,300 274,300 Building Value: 127,200 127,200 Land Value: 147,100 147,100 Market Land Value: 147,100 Chapter Land Value: 11 http://csc-ma.us/PROPAPP/display.do?linkld=1891129&town=NandoverPubAcc 5/17/2012 N O N } LL O M LO Q ,..,._.,y O (n4 00 N R x ON 0 C C p 0 J J Al 00 ci �� Y 1C' ✓ s e . =' I 2 2 Z co, i O t, 00 `-i `- Q P: ice' o,0 O Z�{ paps Q O LL ~ Z `� m cc �LU Z �d-0 W'C O JJ if ~ ON � ) Z jyoo 0 $Q1 " N N Z :)w Z �pl O N N , � .. • Zo ~ a= t Q U) U) co) Q � m m r < VW i Ato !d€ m� CO WN O O O M M 'cY t rl- :! w y'co C W a Q' U+ dj H H O Z a- 'o Q r- (0 o, o Lo E w. co # 0 (6 C13 }QEf(r�k. >��i��N O V Q C U) (n .p LL L 'com;W UiY€OriO. � Q LL m of l,U),U QZ- I< d O ,m Q L a l Z tl)';CO Cl) �N�w �Lo N�f � �� t V O rnFo , fr-�a S P 4 N Ml.. N O ` ,Q as rn. Z�lQpl= QAC# m.-m�. O E,.o iA i Date .... W. n. s.......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...4'J��..�..e..ti e -......... r". ...... �. ..5....1.... : has permission for gas installation ....".�.►"Q:°` '.......................................... in the buildings of.... ?.:n.W �- ' ................................................................................. ......�.i.e. at ........ �.............................................. . North Andover, Mass. �z Fee..A ..-......... Lic. No?...................... ..................:....................... GAS INSPECTOR Check # � v L - 9675 A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY oriMA DATE _-f PERMIT # JOBSITE ADDRESS OWNER'S NAME OWNERADDRESS � -�1 • _ -_--_,r _ TEL,_-- --_-_FAX JJ Tp�T OCCUPANCY TYPE COMMERCIAL [ J� EDUCATIONAL RESiDENTiAt, CLEARLY NEIr RENOVATION: El REPLACEMENT: ( PLANS SUBMITTED: YES 0 NOR[ APPLIANCES -1 -- FLOORS--► sSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER ---j __.. _.. COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE J __j --- FRYOLATOR_�-.� -_ I FURNACE - I iEDi _ — ....... _ GENERATORfi si cS1 = I .-- 1 _ _._l ---._i ....._ .._____I _ f .._ _.._I I c" ......,. ,....I .... ......._. GRILLE --- _ INFRARED HEATER F7117-7-1 _... ,_ LABORATORY COCKS` -____.J __ _I .J �.-_j.�----_ — MAKEUP AIR UNIT _-- == _,-- OVEN POOL HEATER ROOM/ SPACE HEATER . ___ (— __ i _, _ ► I _ . _ ___. . _ _,,. ; t ._ _1 ..,:._ ROOF TOP UNIT.._..__....� i ,..:_ -_ - .r. TEST _ I J .-..-._=:1 .,_..___! _ �.._.._. ._._.,...1 _.. I __.._1 ..__. J _._.....I �Nr UNI' HEATER_. _ ..._� UN =NTED ROOM HEATER `yy - -- �- --' ". ER HEATER -1 - I ' ! - --I . �.S _ f INSURANCE COVERAGE I have a current -liability-insurance policy or Its substantial equivalent which meets the requirements of MGL, Ch.142 YES NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY1 OTHER TYPE INDEMNITY [ BOND [j] 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 0 AGENTi SIGNATURE OF OWNER OR AGENT 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 YAII be in co fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER-GASFITTER NAMED✓ Q %�i� LICENSE #LZ� i' _ SIGNATURE MP E] MGF j JP&f JGF LPGI ®-- CORPORATION D# PARTNERSHIP El#= LLC COMPANY NAME:` . :..... J e ADDRES @.1'1 e - CITY STATEZIP . EL FAX FAX CEL 'A �-�� ®t�� 1 � � � �� �� 9 The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA. 02111 www.mass gov/dna Workers' Compensation Insurance Affidavit: Builders/Cont°actors/Blectricians/Plumbelrs Name (Business/Organi'zation/individual):_ Address: 2 8 )LMY ,a- )7 -�v ► n v<< Arm ,� City/State/Zip: C� d V nJ I A b) � Phone #: c)��- ?�6-��6a Are you an employer? Check the appropriate bog: Type of project (required): 1. ❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction f employees (fall and/or part time).* have hired the sub -contractors listed on the attached sheet. 7• E] Remodeling 2. 1 am a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. E]Demolition working for me in any capacity. workers' comp. insurance. 9• E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. El am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbingxepairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance 1 ired• re q u employees. [No workers' 13F] Other comp. insurance required.] 'Any applicant that checks box #X must also fill out the section below showing their workers' compensation policy information. t -Homeowners who submit this affidavit indicating they sire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheekthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. fain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy ## or Self ins. Lie. 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 tine 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 maybe forwarded to the Office of Investigations of the DIA for ikurance coverage verification. I do hereby cer'qy ujPer the p ins and penalties ofperjury that the information provided above is true and correct. Phone #: e-7C6-II/b� 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. EIectrical 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 Ideal 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 ofpublic 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. B e 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. he 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 mmber 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 (ifnecessary) 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 maybe provided to the applicant as pro of that a valid affidavit is on file .for future p emits or licenses. A new affidavit must b e 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 burn 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 anal fax number: The Commonwealth ofMumachimotts Departmouto ladustdal,Araddeats Office o£Iuvestigatim 60 WashiWou Street Boston, MA 0.21.1.1. Tei, # 617-72,7-4900 -4900 est 406 ox 1-877- TASSA FE Revised 5-26-05 Fax # 617-727-7749 www.Mas%goV1dja e4-11 3 ETON MA 01949-1$49- 22392° 223971 r - GENERATOR APPLICATION DATE' 0- I )' /H n LocnnoN:36 6L., OWNERS NAME: 4� GENERATOR kw � 7 NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: S��v e- 0 PHONE NUMBER: I"'? g - 7��" �7 ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY 1 LOCATION OF GENERATOR: *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL 1-i ��S ow (21 Date ... %U .-.C.grj. - a� - - 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that "q has permission for gas installation in the buildings�of ........................... at -? . . ..... v ...... North Andover, Mass. Fee,. Lic. Nc�AQIX ... ............... Imo"'' GAS INSPECTOR Check # 5768 v A NIA%ACHLTSErrS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITDNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS T Building Locations 3� (/— e 2 ze QC Permit # �f?& 8 Amount $ Owner's Name /` Cl- (j �� 2 / vsf, New Renovation ❑ Replacement © Plans Submitted ❑ (Print or type)/f � JJ// C ec(one: Certificate Installing Company Name / , 13 A !�'Q /i Corp. Address Z GJ A ti e. /Mxg . e ❑ Partner. Business Telephone -2 — — Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No13 If you have checked yes, please ' icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 0 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 �. �, .... •....„ . u� a all if vilifativil I uuvc suounn.Lea for enierea) In above application are true and accurate to the best of my knowledge and that all plumbing work and installations pertVziipd under Permit Issued for this application will be in compliance with all pertinent provisions of the !Massachusetts State gasP6de and Chapter a.of the General Laws. r By: Title City/Town .APPROVED (OFFICE USE ONLY) Sum ature of 13 Plumber 0 Gas Fitter 0 Nfaster journeyman sed Plumber Or GasFit u,ense um er • ,7TH. FLOOR (Print or type)/f � JJ// C ec(one: Certificate Installing Company Name / , 13 A !�'Q /i Corp. Address Z GJ A ti e. /Mxg . e ❑ Partner. Business Telephone -2 — — Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No13 If you have checked yes, please ' icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 0 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 �. �, .... •....„ . u� a all if vilifativil I uuvc suounn.Lea for enierea) In above application are true and accurate to the best of my knowledge and that all plumbing work and installations pertVziipd under Permit Issued for this application will be in compliance with all pertinent provisions of the !Massachusetts State gasP6de and Chapter a.of the General Laws. r By: Title City/Town .APPROVED (OFFICE USE ONLY) Sum ature of 13 Plumber 0 Gas Fitter 0 Nfaster journeyman sed Plumber Or GasFit u,ense um er The Commonwealth of Massachusetts Department of Industrial Accidents 1R Office of Investigations 600 Washington Street 4 .� Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: Wk 14f_ AA A City/State/Zip:% 71ut tk eel 07,4. 6 Phone c-2 1 o y1> 0 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. Ll I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.[]-P'lutfibing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation. 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' 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:_ 36 Pe 2 4ey 12-/.1 City/State/Zip:,V,a,,,J4,,,eR 14A 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 the pains a �ltiesperjury that the information provided above is true and correct Si nature: Date: /D >aAl 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 burn 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 Date ... Ao- A f - 0 6 ....... 4..T .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..�.. ....... #04 has permission to perform ....................... wiring in the building of...... .............. ... ...................................................... ... ..... I ..... ;%,/) , ............ .North Andover, Mass. .... ... .............. .. Fee .......... Lic. No./.y74 QQ ELECTRICAL INSPECTOR Check # 7006 ems' '- Commonwealth of Massachusetts Official 41 Use Only Permit No. N{ Department of Fire Services 4 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS, Rev. 11/99 j (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAU 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: /0 — % Y rim Citv or ToNvn of: 2&,e To I170 (;,.;nc rtr r of By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant / �irit Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building �S,u6eF� 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: Completion of the followin.L, table mar be waived br 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. iii-nd. o. o mergency tg ting I Battery 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 Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers HeatPump Totals: Number Tons KW No. of Self -Contained Detection/Alertina, Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KWSecurity Systems: No. of Devices or Equivalent No. of WaterKms, Heaters No. of No. of' Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, oras 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 covera in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) e- (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be regyested in accordance with M' EC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on th' pplica ' n is true attd complete. [�J FIRM NAME: 040 0eG7C� � e6u CTN LIC. NO.:, 314 Licensee: 440/0 11460, & Signature LIC. NO.: (If applicable, enter "exempt - in the license number line Bus. Tel. No.: 977 6,9 2- Address: S& �5�-9YctA ST 44 --',tom 1�91 0 Alt. Tel. No.:97r 3-7 S 7 3Y 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 SignatureTelephone No. PERMIT FEE: S, �i