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HomeMy WebLinkAboutMiscellaneous - 39 ROYAL CREST DRIVE 4/30/20181 1-j -.? 'D Date .... .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING � H Q- M L4 This certifies thatD ......... ............ has perniission to perform ............ . ............... **"** ...... wiringin the building ........................................................................... 3.cl N rth A dover, Mass. at '7 PE Fee .... .......... Lic. No—JAV) ................ ......... .. . .. .... X- ........ ....................................... ELECTRICAL INSPECTOR Check# 13 311,9 t-� or- �onintonaisa( o� ///aeeactuedalt official Ilse Only permit: No. '1 _ �A�Y[aNamRnf, O�.JbrR ��arvicrab Occupancy and Fee Checked a BOARD OF FIRE PREVENTION Riz-OULATIONS )l cv,. 1/07) (leave blank.) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be perlbrmcd in ace0rdancc with the Massachusetis I locirical C'odo (MEC), 527 CMR 12.00 (PLEASE PRINT.I,NINK OR TYP ALL INTORMA.TION) City or Town of: �.s�ti1, AtN� Y _ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. pv,� Location (Street & Number) 9,w, C(P-5i�Q1�1V£ t C1` iAtill�ji C` 18\1M\,�&, Owner or Tenant �t�'�Ct� ���'Yelepbone No -, in -6 ig-645-A Owner's Address EQ _..f�4AL ws"C' Drm, -hmjLIs this permit is conjunction with a building permit? Ves F1 No (Check Appropriate Box) Purpose of Building—zW— ,j1.t L. tv1T Utility Authorization No. Existing Service Amps / Volts Overhend ❑ Undgrd ❑ No. of Meters New Service Amps/ - Volts ' Overhead EJ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed UPlectrieni Work: C:'mm�letlon nf'!lre.lr�lln,viri�? table nay be wgived by the lrrspectOr of 13'lres. 1r15T�t No. MRecessed Luminaires No. ofCcil,Sus Paddle i+ans p (Paddle) No. o 'Notal Transformers KVA, No. of Luminaire Outlets u No. of Hot Tubs Ci�eln+crAtors KVA No. of luminaires Swimming Pool Alcove © tt� rnd. rod. o. off' Emergency ig tog Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Cas Burners D ane o. o )Initiating tin Devices No. of Ranges No. of Air Cond. Toys No. of Alerting Devices of Waste Disposers Heat Pump Total u. mer . . ... ......... ..'.f...u....n..s.. ........... o. o Sell-ContaineNo. 'betectiopJAlerting Devices No. of Dishwasllers Spnce/Ar'en Keating KW Local 0 uoicipal 0 Ot1jer Connection No. of Dryers _ Pleating Applialnees KW T Security Systems: No. of Devices or C, uivolent o, o Water KW No. of o. of Data Wiring: Heaters Si tts MR1180s No. of Devices or Equivalent No. H y dromnssage Bathtubs No. of Motors Total PIP a ecotntnun eat�ons Wiring - No. of li)eviceg or 13 Itiva�cltt OTHER: Attach addidlonal (.lrltul it rlesh-rd, or as required by the Inspector of Pfires, Estimated Value of Electrical Work: 16,C)DO (When required by municipal policy.) Work to Start: I ; Inspections to be requested in accorda.noc with NiEC Rule 10, and upon completion. INSURANCE COVERAGU: Unless waived by the owner, no poinit for the performance of elcetrical work may issue unless the licensee provides proofof liability insurance including "complcted operation" coverage or its substantial equivalent. The undersigned eortiaes t:hal such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONP,: INSURAN0I O BOND D CYPHER [] (Specify:) I certify, under Ute pains and penalties of perjutjy that the injrrrttrtrtiou un rh.i.s application is true and contplete. FIRM NAME: Newport Eloctric LNC. NO.: A20803 Licensee: David McMullen Signature LIC. NO.: 116088 (Ifapplicahle, enter "exenipl., in the Jicensc munber Une.) Rus. Tel. No.:_441-263-0527 Address: 200 Hig.hpoint Ave. Portsmouth, R102871 _ _ Alt. Tel. No.: 617-9084193 *Per M.G.L. c. 147, s. 57-61, security work requires Department of public Safety "S" License: Lic, 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 requiremew, t am the (check one [x owner ❑ owner's agent, Owner/.Agent Signature Telephone No._-_---_ PEI R)Wff I m $ /�2 �- NORTH oq"i Iu .4'�M * O0 f. , NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street Building 20 Suite 2-36 North Andover 1SSCHUS�� Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE: NAME: ADDRESS: %� � � S % %�% 1 l% �w ZONING DISTRICT: pi TYPE OF BUSINESS:�5/G�G/(� BUILDING LAYOUT PROVIDED: AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: BUILDING INSPECTOR SIGNATURE: BUSINESS FORM FOR TOWN CLERK YES YES 0 01 2.46 Home Occupation (1989/32) 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 building for living purposes. Home occupations shall include, but not limited to the following uses; personal services such as furnished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business, or the manufacturing of goods, which impacts the residential nature of the neighborhood. 4. For .use of a dwelling in any residential district or multi -family district for a home occupation, the following 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 the home occupation and residing in said dwelling; b. The use is carried on strictly within the principal building; c. There shall be no exterior 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 dwelling unit so used, not to exceed one thousand (1000) square feet, is devoted to such use. In 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, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design not customary in buildings for residential use. �% J� f✓' r Date NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Stmet North A dover Tel: 978-688-9545 . Fax: 978-688-9542 B USEVESS FORM, OR TOWN CLERK DATE: 6 FIN NAW a �� U V-0� ,1 ADDRESS; ,ONMGDI8TIUOT: TYM OF BUSINESS: BUILDING LAYOUT PROVIDED, .A7VAILA_i.LHPAR4IG SPALL cv-vk 6¢P,'ce- C ZONING EY LAW USAGE: YES NO G Ii�TSP'EOTG�.. �IG�TATLT.P�E BUSINESS FORM FORTOWN CLERK 2.40 Horne 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 building for liinng piuposes. Home occupations shall 'include, "b -ft fiot'limited to the following uses; personal services such as f rnished by an artist or instructor, but not occupation involved with motor vehicle repairs, b=4, patlors, auirnal kennels, or the conduct of retail business, or the manufacturing of goods, which impacts the residential nature of the neighborhood; 4. For use of a dwellii ig in any residential district or multi -family district for a home occupation, the following conditions sha11 apply. a. Not more than a total of three (3) people may be employed in the;'hom occupation, one of whom shall be the owner of the home occupation and residing m said dwelling; b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not custamaw with residential buildings, d. Not more than twent five (25) percent of the oxisting gross floor area of <tha dwelling unit. so used, not to exceed one thousand (1000) square feet, is devoted to'such use. fn connection with such use, there is to be kept no stock in trade, commodities or products which occupyr space beyond these limits; e. There will be no display of goads 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 ex=terior appearance, emissioif of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design_ not custoi-nary in bindings for residential use. Signature Date .42.Ali Date ...... .. .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies tha\t\.A 2 L"— � I P. J L bn -c�i tk.... .......................... has pennission to perforni V, ...... ".. )Q�4Y� V—m 615A" ......................... wiring in the building .......................................................................... r, 1�61 at ........ �w I ...... Of).tA tZ7North Andover, Mass. ,Fee .... .. . ............ Lic. Nol(�w) ...... ........................... . . .. ... .. RICAL INSPECTOR Check # r Commonwealth of Massachusetts official use my Department of Fire services Permit No, 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 WINK OR TYPE A ,r, rNI:O TION) Date: City or Town of: NBy O`f i lNl�?Y this application the undersigned gives notice oTo is or er intention to perform heelectrical Location wok described below, Location (Street & Number) �O � Owner or Tenant �4t �+ca Na�M MSA, 01 Owner"3 Address v°'r L� Telephone No, 9 78- &FQ, ._O L cY�IS-- Is this permit in conjunction with a building permit? yC9 Nd�ve o iF54 Sir )` ❑ t Purpose of Building DlJu AL1 No 9 (Chock AppropriAte Box) Existing ServiceAm Utility Authorization No. s N v p _ _ _� Volts Overhead ❑ Undgrd ❑ No, of Meters —��' -� Amps / Volts Number of Feeders and Ampacit� Overhead ❑ Undgrd ❑ No. of Meters _ Location and Nature of Proposed Electrical Work: lKitic Ju lin —N hAC1lN We c,.>e PMVM0 C4"5 letion o 'the ollowin table ma be waived b the Ins ector o Wires. No. of Recessed Fixtures No, of Cell.-Susp. (Paddle) Fans 0.0 0 No. of Lighting OutletsNo. of Hot 'Pubs Transformers KVA No, of Lighting Fixtures Generators KVA Swimming Pool Ove ❑ rt- o. 1151 ency g No• of Receptacle Outlets rnd. rnd• ❑ Batfe Unit 63 ng No. of Oil Burners No. of Switches FIRE ALARMS No. of Zones .. No, of Gas Burners 0-0 otee on an No. of Ranges Initiatln Devices No. of Air Cond' otal No, of Alerting Devices ea um No, of Waste Disposers p um er ons ns Totals: ' No, of Dishwashers Space/Area HeaDet ctlon/Alertin nAevices ting KW No, of Dryers Heating Appliances LOCnl❑ unlc a onnecttion [I Other 0.0 ater KW ecur ty stems: I�eaters KW o, o No, of Devices or E uivalent 010 Data Wiring: Signs Ballasts No. f Devices or E uivalent No, Ilydr( massage Bathtubs No. of Motorsecmun cat ons r ng: Total HP a om A'R,YRV*j-I- OTHER:Ej L�C�,�(L�C �,�C• No, of Devices or E uivalent I{lo cJ T1 W (ISN } \ s 3 W C, 11 o INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electricalas �by the - To- .!ltach addUlonol deloli lfdealred, or as required by the Inspector of Wires, ,- the licensee provides proof of liability insurance including `bompleted operation" covorage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit substantial Work may issue unless CHECK ONE; INSURANCE T BOND g office. ❑ OTHER ❑ (Specify: Estimated Value of Electrical Wor 1 .�,� (When required by municipal policy.) (hxprration Date) Work to Start; �il Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties o er ur that the Information on this application is true and complete. FIRM NAME: Ne,l,� fp l y, Licensee: LTC. NO,:d (IJapplicnble enter exempt "in the heet',re number line,) Signatur Address: � LIC. NO,: (, O OWNER'S INSU Por o�, d �t`3`1 Bus. Tel. No. RAN i WAIVER: I am aware that the iioensee does not have the liability Alt' Tel, No,- 3 requirod by low, By my signature below, I hereby waive this requirement, I am the (check one Owner/Agent ty insurance coverage normalcy Signature owner owners a en Telephone No. PERMIT FEE: $(} is OC .; 11,11e (,0111rt7ro,n")ealth of'Ahmsachi+fsetts 11MMM De,Partttrent. ofIlld"Strial Accidents h a Office of Investigations I Cottg)'ess Street, Suite 100 Boston, MA 02114-2017 WNINr,Inass govltlia Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers )nficant Tnfnrm a+;n" AK;"-ir r X711 NaIlle (Business/Organization/Individual): r- � Address: Rm JLk Y'A,v%J' City/State/Zip: okk WMU +e - I Phone #: r . , D, - Ar ou an employer? Cheep the appropr'iate box.- ox: am 1. i. am a employer with 4• D I am a. general contractor and I Type of project (required): employees (full and/or part-time).' 2, © I, a.m a -sole have hired the sub -contractors listed the �' i� New construction proprietor or partner, ship and have no employees on attached sheet, 'these sub -contractors have 7. �] Remodeling working, for me in any capacity. enrtployees and have workers' �' [ Demolition [No workers' comp, insurance comp, insurance.I 9. [�Building addition t'�st required.] 3. I am a homeowner 5, EJ We are a. corporation and its 10 10KElectrical repairs or additions doing all work myself [No workers' comp, officers have exercised their tight of exemption per MOL ] 1.0 Plumbing repairs or additions insurance required.] t c, 152, §1(4), and we have'no 12 -El Roof repairs employees. (oto workers' 13.0 Other comp. insurance required 7 *Array applicant that ehdcks box 41 must a.Iso fill out the section below showing their workers' compensation policy information, 1, Homeowners who submit this affidavit indicating they are doing all work and then hire outside cohtractors must Submit A newffid affidavit indicating such, em tContraOtors that chick this box must attached an additional sheet showing the name of the subcontractors t+nd stare whither w not davit entities have ployers. !( the sut� eontrpctors have employees, t)xey must provide their workers' comp, policy number,those I aril an enrployer that ispro viding N,o> kers ° corlrpensation insurance for >ary er�rployces. Below as the policy antijob site do arntatiorr. f Insurance Company Name-$Aea Policy # or Self --ins. Lic, #: J� iJxpiration Dal:c: C/ /101 Job Site Address:�pVe�I.t.'! � City/State/7ip:. ve -A 61S- ►- Attach a copy of the vvorlter•s' compensation policy declaration page (showing the policy numlber 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 atid/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 verif cation, I yin fr.ereG cern p nnticr lir arra rad etralties o 'ler• itri� that the in ornrativn provided above is true and correct _ ,0 -A Vicial use only. Do not write in this area, to be completed by city or down of City of Town: Permit/Liccnge # Issuling Authority (circle one): 1, Board of ITealth Z. Building lbepartmertt 3. City G. Other /Town Clerk 4, Electrical Inspector 5. Plumbing Inspector Contact Person: Phone##• rl OVA Ei HCl i S5UE5 THE =POLL( R'£O t EI ED MAc i s . I c AClJ,Rf3" NP013 OP ID: LS �----� CERTIFICATE OF LIABILITY INSURANCE °"'�(""�°°'��) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ISERT'IFICATE HOLDER, T CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE 'aF 09LDER. T BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT ;BETWEEN THE ISSUING INSUREII AUTHORIZEDHIS REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. i FORDED BY THE POLICIES IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject o the terms and conditions of. the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsements . PRODUCER )F Dwyer Agenoy D.F: Dwyer Insuranc�Aenc� 18 Bellevue i4venue P ----_Newport, RI 02840 401-846-9629c Nolt_401-848.9829 )anis/ F. Dwyer III _ ds.r�a�e�__ INSURED Newport Electric Construction Corp 200 High Point Ave, Suite B5 Portsmouth, RI 02871 Foremost Scottsdale Insurance Company Beacon Mutual Insurance 297 N THIS IS TO CERTIFY THAT THE POLICIES OF,It: URANCE LISKED 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 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF 5UCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE __.._......_....._.. `___—•— —� GENERAL LIABILITY POLICY NUMBER LIMIT$ A X COMMERCIAL GENERAL LIABILITY SCP006046448EACH OCCURRENCE $ 1100010 CLAIMS -MADE XOCCUR 12/30/2013 12/30/2014`-- — €Ot1:.22.m,[[3()se $ 300 MED EXP An one arson PERSONAL & ADV INJURY $ 1,000,1 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,001 1 POLICY PRO' LOC PRODUCTS • COMP/OP AGG S 2,000,1 AUTOMOBILE LIABILITY A ANYAUTO s O B D SINGLE ll 1 ALI SCP005046448 AUTOS NEO X SCHEDULED AUTOS 12/30/2013 12130/2014 E acc an BODILY INJURY (Per person) g HIRED AUTOS X AUTN OWNED AUTOS BODILY INJURY (Per accident) g PR PERTY D GE ----.—._—_ UMBRELLA UAB X OCCUR E 1 �._..-- B X EXOESS LA9 CLAIMS -MADE BSOOI9598 12/3004 EACH OCCURRENC$ nD D ETEN cTMPENBAnoN AGGREGATE 6– --_,_ -- AND EMPLOYERS' LABILITY C $ ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBEREXCLUDED? 68861 WC STATU- 0TH• ❑ N/A (Mandstory In NH) If yes d"Wi under o DE GIR PTI N OF 01/18/2014 01/18/2016 E.L. EACH ACCIDENT g 600,0 OPE TIO § bel w �� .e �.. .. A Empl Prac Liab ' E.L. DISEASE • EA EMPLOYEE3 SOO,O SCP006046448 12/30/2013 12/30/2014 E.L. DISEASE • POLICY LIMIT $ 600,0 60,0 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach CORD 101, Addhloexl R*Mrks Schedule, If more 11104** Is required) G�„ In ` .-. y a. 0 _.1,. - a. �.� • 1 � 1, „ CERTIFICATE H LDER CANCELLA ON SHOLD ANY UEXPIRATOtONHDATE VTHEREOFI�ENOTICE Insured's Copy THE POLICIES IBE CANCELLEDLIVEREO RN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel F. Dwyer III ACORD 26 (2010/06) The ACORD name and logo are registered mar s2Of ACORD D CORPpRgTION.. Ail rights reserved. f 1, ✓ 3 2 P -l-, � L I . I 03b,2 yA0 T" 0" 0 SACHU Date./ —le— / / . .......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... S 7-7 (—/ 4� t- .......................................................... . ...... < has permission to perform ...... r ... AW..&. ... wiring in the building of ..... a ....... North Andover, Mass. Fee.(..2..-.t..7. ...... ...... Lic. No..1.6;�674 ............ R�C Check A' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. u,p BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 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 # .3 9 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 New Service Amps Volts Overhead Undgrd Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Upgrade Emergency Lighting No. of Meters No. of Meters 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 ❑ E] No. o. o Emergency Lighting 6 rnd. rnd. Units No. of Receptacle Outlets No. of Oil Burners IFIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices I No. of Waste Disposers Heat Pump Number ........................................ ...... Tons .......... KW No. of Self -Contained Totals: Detection/Alerting 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 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 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 018D LIC. NO.: A11067 Licensee: Karl Gonsiorowski Signature ��iy�y� LIC. NO.: E31598 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-352-9994 Address: 108 Tenney Street Georgetown, MA 01833 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. ----7 Owner/Agent PERMIT FEE. $125.00 Signature Telephone No. D /-r-- l/ -- i .- 1l G�, / I ��"y Y n I