The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 36 ROYAL CREST DRIVE 4/30/20189 ��1 +.�..: M�.Om 'c�`. .,¢ i�� '�; .z 1^.�n.:i1 W:�� .0 Date . ........... . 5 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .� ... C� ................................................ has permission to perform ....... ........................ ............ wiring in the bulldin� of..,.. ......................................................................... at ............... ,North Andover, Mass. Fee .............. Lic. N ...................... ........................................................... ...... ELECTRICAL INSPECTOR Check 4t 133 6 M� officitll Use Only l�atftntanweat� o� //Iaee�c�auanL�t 2- �4�tENf119Rlff D� JbrN �aryicrae - -- -- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] ponve lilanic.) ,A,PPLICATiON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be pedbrmoci in accordanoc with the Mossachusetis Electrical Code (MEC), 527 CMR 12.00 (PLL, ASE PRINT tAT ,INK OR TYl'H ALL INFORMATIOIV) T)a.te: City or Town of: PC—N' Atw,��,�,r To the bnspeclor of Wims: By this application the undersigned gives notice of his or her iiltention to perform the electrical work described below. Location (Street & Number) q \, CMSN "i�-�Aivoml- SmUlo # Owner or Tenant6 V �— Telephone No. �1�61a5 Owner's Address 60.4ko-I&L r -W -S -V ' mef ►fin p _ T 1"4N.� Is this permit In conjunction with a building permit? Ves _ Purpose of Suildinige+,jl*tt �11N1�i Existing Service Amps / Volts Overhead - --- ----- Overhead f..:1 No 9 (Check Appropriate Box) Utility Authorization No. New Service Amps _/ Volts Number of Feeders and Ampneity lindgrd ❑ No. of Meters [Jntlgrd No. of Meters Location and Nature of Proposed Electrical Work:w�-�p1m- yew ,�c�i�.> Fk��t" 't1,�� w�l.\ Ux ►'na nth AF''i5 (7mmnlartnn nfthr. 6Jllf7lUiHa fable niav be waived by the Inspector of wins. U!;TQ1 No. of Recessed Luminaires No. of Ceil.••Sus . Paddle Pons p (Paddle) r cifTotal Transformers MCVA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA No. of Luminaires Swimming Pool AY�ovc ® rod. rod. o• o'f iL% ncy rg log Battey Clnit'a No. of Receptacle Outlets No. of Oil Burners TIRE ALARMS No. of Zoines No. of Switches � No. of Gas Burners o. o t ng Dane Initiating Devices No. of Ranges No. of Air Cond. •Tuns No. of Alerting Devices No. of Waste Disposers eat um Tutalq u*. .! funs IC3V o. Of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area I-leating IOW Local 0 , unicipnl 7 Ofller Connection No. of Dryers _ Heating Appliahces Kir �T Security 5 stemis: No. of Devices or G uiv:tlent o, a Watery No. of o. of Data Wiring: Heaters Signs Ballasts No. of Devices or T uivalent No. Hydromassage Bat:lctubs y No. of Motors Total HP c No ofDe cations Wit -ink., No. or Devicesor i -g uiva�ent _ OTiiER: Allach additional ek-, ail fl clesirrd, or as required ky the inspector ref Y' ircds, Uimmted Value of Electrical Work: (When required by municipal policy.) Work to Start: 1; inspections to be requested in accordance with MEC Rule 10, and upon completion, I.NSURANCIE 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 certifics that such covcragc is in force, and has exhibited proorol'same to the permit issuing office, CRECKONi3: INSURANCE O BONi] D OTHER ❑ (Specify:) I certify, under thepains modpena/ties gfperjirrl?, that the att/brouption opt dais application is true and complete. FIRM NAME: Newport Eloctrlc LTC,. NO.: A20803 Licensee: David McMullen Signature .� LIC -NO.: moss (lfapplicuble, enter "exempt" in the license number fine.) - — Bus. Tel No ---4.0.- 2;999L Address: 200.Highpoint Ave. Portsmouth,, R102871 Alt.Tel. No,; 617-9084193 *Per M,G.L. c. 147, s. 57-G1, security work requires Department of public Safety "S" License: Lic, No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does trol have, the liability insurance coverage normally required. by law. By my signature below, I hereby waive this requiretncnl., t nm the (check one) [x owner owner's agent, Owner/Agent Signature Tclepltmte No. PE-RYtT rEE. $ 1b?5-- 11 J 2.44........... r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Use Permit No, Occupancy and Pee Checked :ev. 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 CMR 12.00 (PLEASE PRINT rN INK OR TYPE AL4INF O City or Town of: �IOY TION) Date: A BY this application the undersigned gives notice Ns oQWintention to perform To theenspeetor of fres: Cr Location (Street & Number) electrical work described below, P.�l t,S i �. Owner or Tenant A l MJ r ► CO K)nll I,- _ • , a Owner's Address Is this permit in conjunction Witt, a building permit? Purpose of Building Yes ❑ No � (Check Appropir to Box)"_ D W e � 1 Utility Authorization No. Existing Service Amps / rd ___._Volts Overhead [] Und Amps / g E] No. of Meters __Volts Overhead ❑ Und rd Number of Feeders and Ampacity____ g ❑ No, of Meters _ Location and Nature of Proposed Electrical Work: 1 eS CL - ck Ymlii aL'sZI it letion o 'the ollowin table ma be waived b the ins ector o Wires, No. of Recessed Fixtures No, of Cell-811sp, o. o p (Paddle) Fans Transformers o a No, of Lighting Outlets KVA No. of Hot 'Pubs Generators KVA No, of Lighting Fixtures Swimming Pool °ven- ❑ o. o rnergency g ng No, of Receptacle Outlets rad, rad. iE3atte Units No of Oil Burners No. of Switches FIRE ALARMS No, of Zones No. of Gas Burners 0.0 otee on an i No. of Ranges otal Initiatln Devices No. of Air Cond, No. of Alerting Devices ea um No. of Waste Disposers p um er ons ns Totals: ' No, of Dishwashers Space/Area Heating nKWbet ctionlAlertin Devices ❑ unic a No. of Dryers Heating Appliances Local onnecttfon ❑ Other 0.0 ater KW ecur ty ystems: heaters KW .010 010 No. of Devices or E ulvalent ata Wiring: ...'signs Ballasts DNo. f Devices or E ulvalent No. Hydromassage Bathtubs No. of Motors a ecommun cat ons r ng; Total HP ARWW NT OTHER: 6 L-C—No, of Devices or E ulvalent L__._—• &�Se �,rd, Iie,i itiN i r S 3 i,J ail INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical as r �QYMo S�Q� Attach addlUona! detail f dertred, or as required by the Impactor of Wires. the licensee provides proof of liability insurance including `t:ompleted operation" covorage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the or , substantial work may issue unless CHECK ONE; INSURANCE °r BOND permit issuing office. ❑ OTHER ❑ (Specify; Estimated Value of Electrical Wor ' r (When required by municipal policy.) (hxptrahon llate) Work to v Start; `' Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties o ell that the Information on this application Is true and complete, FIRM NAME NC',vJ iP I y, CL Licensee: LTC. (If applicable enter "&entp1' in the lice re number line,) Slgttatur c LTC. NO.: (�, 0 Address: Bus. To). No. - OWNER a� -� 'S iNSURAN E WAwin IVER: I am aware that Phe Licensee does no has ot�l 1 shill requirod by law. $ Alt. Tel. No, - 3 Owner/Agent Y mY Signature below, I hereby waive this requirement. I am the check one insurance coverage normally Signature q ( owner owners a ent, Telephone No. PERMIT FEE; $ 3 - U oil OC I to [..or>'ttnroartrealth 091'assachccsetts IRE== .Department of,Ti1drsstt ial Accidents Office o fXnuesti/; ation v 1 Congress Street, Suite 100 Boston, MA 02114-2017 wWKI'tnassIgovIdia Workers' Compensation Jusuurance ,Affidavit: Bui.Zders/Contra.ctors/Electricians/Pllumber s nr►lirant Tnfnv-*"(b"-- Name (Busnacss/Organization/Individual):Sf—W—P-6r—+Q—IrC--0 Address: Am l kale TA,/111- -A _. Ac City/ tatc� /&p: d l'YII�U ) %ll" (f � Ph orae #. _ ArDfYOU an employer? Check the appropriate box- IIN 1, am a employer. witl-r� 4. �] I am R. general contractor and I employees (full and/or part-time), 2, [11, in a'sole have hired the sub-corktra.ctors listed the proprietor or partner-. on attached sheet, ship and have no employees 'These sub -contractors have working, for me in any capacity, employees and have workers' [.No workers' comp, insurance required.) comp. insunmcej 5, We are a. corporation and its 3. ❑ lam a homeowner doing all worlr, Officers have exercised their myself, [No workers' comp. right of exemption per MQ.L insurance required,] t c. 152, §1(4), and we have no employees. [Io workers' comp, insurance re wired CC 050? Type of project (required): 6. New construction 7. Remode tg S. Demolition 9. 1 Building addition 1011 10 Clectrical repairs or additions I I.❑ Plumbing repairs or additions 12 -El Roofrepairs 13.0 Other RAny applicant that chocks bay, 61 must also till out the section below showing their workers, compensation policy information. l' Homeowners who submit this affidavit indicating they are doing all wurk and then him; outside contractors must submit a new Affidavit indicating such, #Contraotors that checac this box must attached an odditional sheet showing the name of the subcontractors and stare whether or not those entities have employees. !t the sub-contrpctors have employees, tJtey must provide their workers' comp, policy number. 1 arra art errrployer that is,lrroViding workers ° corrrpensad(m i'nsrirance for illy erirplopees. Below is dine policy and job site inrntafion. Insurance Company Name:III�� Policy # or Self -ins. Lic. M Expiration Dake: p/ Job Site Address: " Q p1//� T —" City/State/Zip; _ VtR. Q/ •Ys - Attach acopy of the workers, coriu,pens9tiorr policy declaration page (shorving the policy numtber 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 n fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a SCOP WORK ORDER and a tine of un to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA ,for insurance coverage verification. I do frer b cerci t, under tlr ar.rt n Venall1iesurry, that flee in nrnration jrronideri aGdve is tare and correct. QVICial rrse only. Do not »rite in dais area, to be conspleted by City or town official. city or Town: Perrn# Issuing Authority (circle one): 01W 1. Board of )Health x• Building Department I Citgl'I'own Clerk 4, Electrical )[inspector S. PlnmhOn� lila.,., ,�... 6, Other Contact Person. Phone �• b EPARWOF" -11tc-TRII C. ISSUES , THE .,FOLLOW I Nt -cft,'EV V RIZA S.-TEXED MASTER tllt T '�.Rf GI: 4 • �� NEWP013 OP ID: LS �--- CERTIFICATE OF LIABILITY INSURANCE DATE(MA41DtMyy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO 0 E/R0T4 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEHIS I REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IZD BETWEEN THE ISSUING IN$URER(S), AUTHORIZED IMPORTANT: If the certificate holder is rt ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, sub act t the terms and conditions of. the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certltlaate holder in lieu of such endorsements , ° PrtotxxER 30 Dwyer Agenay D,F. D er Insurance A enc 3B Bellevue Avenue P-•-- _ Newport, RI 02840 No E,tu 401-846-9629 -- Daniel F. Dwyer III — r rc Nod 401-848~9829 A : dfdCrAdid wyer tort/ _ INSURENS) AFFORDING COVERAGE — INSUREo ~ Newport Electric Construction~ INSURER A: Foremost Naicw Corp LNSURERB:SCottsdale Insurance COmpany ---. 200 Hlgh Point Ave, Suite BS INSURER c: Beacon Mutual Insurance 41287 .... - _ ._... , Portsmouth, RI 02871 INSURER 0: --.___...,...,.. -- INSURER z: COVERA ES CERTIFICATE NUMBER: F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L►STED BELOW HAVE.BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER; INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SPECT ALL THE THIS TYPE of INSURANOe ALL THE TERMS, GENERAL LIAINUTY POLIC NUMBER -- LIMITS A X COMMERCIAL GENERAL LIABILITY SCP006046448 EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE a OCCUR 12/30/2013 12/30/2014 s (Eo srrsa�eL-• s _ 300,00 MED EXP An one aeon $ 10,00 PERSONAL 8 ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO - AUTOMOBILE LweluTY L PRODUCTS OD UCTS COMPI oP AGO s 2,000,00 s A 7 ANY AUTO 0 8 NED SINGLE LI I SCP005046448 E acct en 1,000,00 AALL NED X SCHEDULED 12/30/2013 12/30/2014 BODILY INJURY (Per person) ; AUTOS HIRED AUTOS X NON - OWNED BODILY INJURY (Per accident) 3 AUTOS PR PERTY O E -- -• UNIBMLLA LIAR $ X OCCUR — — B X ° S UA6 CLAJM84AADE BSOO19698 EACH OCCURRENCE $ wo12/30/2013 12/30/2014 AGGREGATE riKlaRs COMPaTE NNt;AnoN -- D S 6,000,00 AND EMPLOYERS, LIABIUTY 3 C ANY PROPRIETOR/PARTNER/EXECUTIVE Y r N AOR STATU• 0TH• OFFICER/MEMBER EXCLUDED? 68861 (IUe0 story In NH) N / A 01118/2014 01/18!2016 E.L. EACH ACCIDENT If yodescribe under $ 600,00 DE �RP I NOF PERATIONS below E.L. DISEASE - EA EMPLOYEES 500,00 A Empi Prac Liab 1.. DISEASE - POLICY LIMIT S SCP006046448 1411'u1zu13l12/30/2014l 600,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEKCLE3 (Atteoh ACORD 101, _..and Remetka Schedule, If mon apeoe Is required) THE SHOULD THEREOF, NOTICE H DATE ABOVE POLICIES ~VIBE CBE CDELIVERED RN Insured's Copy ACCORDANCE WITHTHE POLICY PROVISIONS,LL AUTHORIZED REPRESENTATIVE Daniel F. Dwyer III ACORD 26 (2010105) The ACORD name and logo are registered marks Of ACORD D CORPOF2ATION•. All rights reserved. 1 > ' I 0 I /4 Il /Z NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 .BUSNESSF0)?MF01? TOWN CLERK DATE: ADDRESS: ,ONMG.DISTRIC�': TYPE OF BUSINESS: Gtelwdellll. (�)4 S G` 0 GL 7 BiT. DING LAYOUT PROVIDED: YES N A.VAiLAI3LE PAER!`SMG 811AMS: .ZONING BY LAW USAGE: YES NO 13LILDING INSPECTOR SIGNATUPIE BUSINESS FORM FORTOWNCLERK 2.40 Home Occupation (1989132) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use• of the b. ilding. for living purposes. Home occupations shall 'include, "but -tot 'lirnited to the following uses; personal services such as finished by an artist or instructor, but not occupation involved wffi motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business, or the manufacturing of goods, which impacts tbi residential nature of the neighborhood, 4. For use of a dwelling in any residential district or multi -family district for a home occupation, the followuig conditions shall apply: a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the: owner of thd hbme, occdpatiou and residing in said divelling; b. The use is carried on strictly within. the principal building, c. There shall. be no ex-ierior alterations, accessory buildings, or display which are not customary with residential buildings; - d. Not more than twenty-five (25) percent of the existing gross floor area of ;the divelling unit . so used, not to exceed one thousand (1000) square feet, is devoted to -such use. 7n connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; e. There will be no display of goods or wares visible from the street; f The building or premises occupied shall not be. rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dusty noise, disturbance, or in any_ -other way become objectionable or defrimental to any residential use within the neighborhood; g. Any such building shall include no features of design- not customary in buildings for residential use. Signature 2Date. . �12 /-1,. -24 ........ 184 TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION oy w) 41 .'S 'qSS CHU This certifies that Ok /-./ .................. w has permission for gas installation .../q 1� 4. ff ................ in the buildings of ....................... at PAY. /I ........... North Andover, Mass. Lic. No. .c1.%F-,7 .. ... )AS l<N:iEPE)CTOFf WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPI.ICATIO.N FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date 12 1huilding Location Permit # Owera Name/ Z,+/12� • New '7 Renovation Replacement Plans Submitted 0 .� I T t t7 C C (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING Co., M. Corp'. 2122 Address 57371/2 SO. UNION ST. Partner. LAWRENCE, MA. 01843 (_J Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter --GL i eQnS Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a5zother type of indemnity Q Bond Ej Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. NEE____ MMEMEMEMENUMEMMME (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING Co., M. Corp'. 2122 Address 57371/2 SO. UNION ST. Partner. LAWRENCE, MA. 01843 (_J Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter --GL i eQnS Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a5zother type of indemnity Q Bond Ej Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property . Owner 0 Agent M 1 hereby certify that all of the devils and information I have submitted (or entered) in above application are true and accurate to the best of mY knowledge and that aU plumbing work and Installations perforntcd undo' Permit isst:ed for this application wiU_be in compliance with all pertinent provisions of the Massachusetts State Gas lade and Chapter 14: of the Cenral Laws. • .. By/TYPE LICENSE: Plumber Title Gas fitter- Si nature of Licensed City/Town: Master plumber or Gasfitter Journeyman 99A3 APPROVED (OFFICE USE ONLY) License Number 103b0 Date ... .?.- /el-- �. �... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that �. C' �'L' G......'�.� ......... .......................... has permission to perform ..4:6; 1 ` ......Ul : .'.'.K`.�{ wiring in the building of ... 4qv!:�� C/2: .5%, .............. ............ at . ��..& / '�a .C..rr�... `....T.......= ...... .. ...C....North Andover, Mass. Feei'n' .Z3.... `' Lic. No../v6�............. ................. ELECTRICALINSPfi R Check # 4 • Commonwealth of Massachusetts Official Use Only.� Department of Fire Services Permit No. �t BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [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 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10-13-2011 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 50 Royal Crest Drive Building # 36 Owner or Tenant Royal Crest Estates Telephone No. Owner's Address 50 Royal Crest Drive Is this permit in conjunction with a building permit? Yes No X (Check Appropriate Box) Purpose of Building Apartment Buildings Utility Authorization No. Existing Service Amps Volts Overhead Undgrd No. of Meters New Service Amps Volts Overhead Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Upgrade Emergency Lighting Completion of the following 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- ❑o. of Emergency Lighting 6 rnd. grnd. 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 Initiating Devices No. of Ranges No. of Air Cond. of Alerting Devices Tonsl IIZo. No. of Waste Disposers Heat Pump Number ......................................................... Tons KW No. of Self-Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent 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 perforrnance of clectrical work may issue unless the iicersee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE x BOND ❑ OTHER ❑ (Specify:) 3-21-12 (Expiration Date) Estimated Value of Electrical Work: Work to Start: 10-17-11 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Stilian Electric, Inc 108 Tenney St. Georgetown, MA 01 LIC. NO.: A11067 Licensee: Karl Gonsiorowski Signature LIC. NO.: E31598 (Inapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-352-9994 Address: 108 Tenney Street Georgetown, MA 0 183 3 Alt. Tel. No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $125.00