HomeMy WebLinkAboutMiscellaneous - 45 CRICKET LANE 4/30/2018 (2) 45 CRICKET LANE
210/107 A-0210 00.0
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Commonwealth of Massa usetts Official Use nl
� Permit No. ��
Department of Fire Se ices
�.�. \VW Occupancy and Fee Checked
BOARD OF FIRE PREVENTION EGULATIONS [Rev. 11/99] leave blank
APPLICATION FOR PERM TO PERFORM ELECTRICAL WORK
All work to be performed in accordance ith the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR T PE L 1 A ION) Date:
City or Town o . To the Inspector of Wires:
By this application the undersigndd gives n ice of hiq or her intent; n to perform the electrical work described below.
Location(Street&N be ) • �,r?
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes..❑ . No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Installation of Security system
Completion of the following table may be rvaived 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 rnd. rnd. Ba tte Units❑ In- ❑ o nits- cy tg mg
No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No. of Switches No.of Gas Burners t 0.of Detection an
Initiating Devices
No.of Ranges No.of Air Cond. Tonal No. of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: I. Detection/Alertine 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. o Water o.o No.o
KW Data Wirin
Heaters Si ns 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 ❑ BOND ❑ OTHER ❑ (Specify:)
Estimated Value of Electrical Work: 6.1V .' (Expiration Date)
(When required by municipal policy.)
Work to Start: 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: Security Services 18 , LIC.NO.:
Licensee: John S. Bassett Signature LIC.NO. 1533C
(If applicable, enter"exempt"in the license number line.) Bus.Tel.No.: 603 594 5928
�i Address: Alt.Tel.No.:
OWNER'S INSURANCE WAIVER: I am aware that the Lic'9hsee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ �,
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the
Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed I�
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the u
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be_deemed_by.thelnspector_of_Wires abandoned_and_invalid,if_he`.. ._
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of 1
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
Purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
_ "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012.
rPermit
Permit/Date Closed: - Z
**Note:Reapply for new permit
xtension Act—Permit/Date Closed:
1 0 2 6 6 ......
i Date.
�10R7M
3r +OpL TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SSCMUSE�
p4y�D %2�This certifies that .......... ....tZ
.......................tr..................................
has permission to perform ........k .-//�`V...........................................
wiring in the building of........RQA.13.�S..............................................
at.... /5.47 ...... ............. . ... .North Andover,Mass.
Fee..4A,/-�"°--� Lic.No J Y941 3...........� � ...
AL INSPE,
Check #
r
(fon nonw1at4 o/M166ac"(f, Official Use Only
g UV �Pa 6.nt 0/
/ Permit No._ Q 2.0
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checkedev. 1/07] leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),127 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORM TIOA9 Date:
City or Town of: A.'-Y27?f 44/00aQC 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)_ Gf;j CRiceET 444.
Owner'or Tenant 222;12' j f a Telephone No,
Owner's Address
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑ 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 !able ingy be waived by lire Inspector of Wires.
rt No,of Recessed Luminaires 10 No,of Cell.-Susp.(Paddle)Fans No.of Total
Transformers KVA
{
No.of Luminaire Outlets 1'�> No.of Hot Tubs Generators KVA
No.of Luminaires ' Swimming pool ove ❑ El Battery
o Emergency g ng
rnd. d. Batte Units
No,of Receptacle Outlets 01 No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners o.of Detectio—ni—an—d—
InitiatingDevices
No,of Ranges f No.of Air Cond. Tuns No.of Alerting Devices
No,of Waste DisposerseaTt um Number ous o.o elf- onta red
Detection/Allertine Devices
No.of Dishwashers ( /' Space/Area Heating KW Local❑ Munictpal [I Other
Connection
No,of Dryers Heating Appliances KW Security Systems:
No.of Devices or E uivalent
No.o iter KW o.of o.o Data Wiring:
Heaters Signs Ballasts No,of Dvices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP a ecommun cations irisg:
OTHER: No.of Devices or E uivalent
Attach additional delail if desired,or as required by lire Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
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 5j BOND ❑ OTHER ❑ (Specify:)
I certify,under die pains and penalties of perjury,that the information.on this application is true and complete.
FIRM NAME: Vk%J i D IiFL C C:TQi CAL C:DtATQ4Z rIA44 LIC.NO.:
Licensee: VqV i D 1 ►A 6 6,q pSignature_ LIC.NO.' (`{!t✓3
(If applicable,enter"exemp!"in the license number line) n. Bus.Tel.No.' `17 F ml+ 2 L
Address: _�� i�rZii7Lfr�i-r 5r TirS,QTI+ ApDoyep, 111!4 1)it "Alt.Tel.No.:-qJ 37� -x'73 f
*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 requirement. I am the(check one El owner ❑owner's agent.
Owner/Agent
SIgnature Telephone No. I PERMIT FEE, $
The Commonwealth of Massachusetts
Department of IndushW Accidents
Office of Invesfigadons
600 Washington Street
Boston,MA 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): PAN1I D EL t CT PZl C AL. Co 1V T R A C-T I N G LL-C,
Address: 97 aELMONT ST-
City/State/Zip: NORT{ I} VOVUQ M4, Mq 5' Phone#: �l B
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 8 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-Contractors 6. []New construction
2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. employees and have workers' Building[No workers'comp.insurance comp.insurance.: 9. ❑ n$addition
required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions
3.❑ I am a homeowner do' all work officers have exercised their I L Plumb' re
� right of exemption MGL ❑ �repairs or additions
myself.[No workers'comp. 1 lro l 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.[:]Other
comp.insurance required.] J .
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside Contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet stowing the name of the sub-coutractnts and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
s
Insurance Company Name: AN OV E R Ameei cAH .
Policy#or Self-ins.Lic.#: W 2 N*-50 9 O i 7 Z Expiration Date: 3
Job Site Address: V� CA-4lOZZ�1 L11/, City/State/Zip: S—
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 goMmge verification.
1 do hereby certify un fp d penalties of perjury that the information provided above is true and correct
« Si ature: Date: 7 2? 1/
Phone#: 9-70 - 661' 12�1 2
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.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
7757 Date.. .7. :.a`�. -.�.1... .
ppRT1y
a? TOWN OF NORTH ANDOVER
F D
' PERMIT FOR GAS INSTALLATION
,SSACH USE'k
This certifies that . . :1 kt4 { f41.�. . .�� a`��? `l�---. . . . . . . . . . . . "
has permission for gas installation .�op . . . . . . .
in the buildings of . . . . . . . . . . . . . . . . . . .
at . . . . . . . . . . .North Andover, Mass.
Fee. 2.5 "`'. . Lic. No..l CS.y. . . . ,1.c1=+ . . . . . . . . . . .
GAS INSPECTOR
Check# ILI5 3
l I
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town.—bk nor ,M,r- MA. Date: -a c -a@��
Perm!
t#
Building Location:_ y.� C V ,' kP L
Owners Name: N't I?
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
Ej
New:❑ Alteration:❑ Renovation:
[9 Replacement:❑ Plans Submitted: Yes❑ No
FIXTURES
DEDICATED
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a m m o o LL x° g g N a ~ 3 3 3 3
-SUB BSMT. o a
BASEMENT
1sT FLOOR
2ND FLOOR
3RD FLOOR
4T"FLOOR
5TH FLOOR
6T"FLOOR
7T"FLOOR
8T"FLOOR
Installing Con1pany Name: le-V5 S S ►'0/-(.I 01 Check some O„r
ct.S ��✓ �f I" (361
�-1ti#iGrate?�
Address: -f acorporation / 8
City/own: `7`ice e ,Sj%te•
Business Tel: ElPartnership
Fax: 6 Y S - 5-5 26
❑Firm/Company
Name of Licensed Plumber: tF k
INSURANCE COVERAGE:
1 have a current Iia_ bility Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 40 No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy-9— Other type of indemnity ❑ Bond ❑ -
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
p
Check One Only
Si nature of Owner or Owner's A ent Owner ❑ Agent ❑
1 hereby ceriify that all of the detalls and information I have submitted(or entered)regarding this application are true and
accurate to the best of my
Knowledge and that plumbing hus
Pertinent provision off t k and installations performed under the permit issued for this application will be in compliance Ivith all
the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
- Type of License: ,y�C
Title
aPlumber 5 9nature of Licensed Plumber
'ity/Town [IMaster
APPROVED(OFFICE USE ONLY) ❑Journeyman License Number:
EATli�O� MA Sd '!4
4
C{t` ASTEENSED A ' lB��t
" x MUES; HE A80V1 (LICENSE 1 O
Ev
,TYlGSBURO, Mi4��Q1874 1II23 ,
t ;
II5/Cd1/I2 784445 .
^,C
OF IOASSAt'U
f "'-Jjy°F"4llIYIt�GRw v eal 3
sRCG1STERED AS PLUMBING
^ CUF�1�;
+ " ISSUES THE A$OVE LICENSS TO
j� = ��ARK tib BU9RGESS , r �4 r
gU ;� SS, PlUM$IRG 8FlEATItJG
' TYN,iSBORO
T.JA
29-85 %„ 05/U':1%12 7 4441
•
Jl";4tll�
2/
Date..................................
1q' f NORTN 9
° t"`°:• "� TOWN OF NORTH ANDOVER
3? •` °t
PERMIT FOR WIRING
,sSACMUSE�
This certifies that ��h&...............
has permission to perf rm . ........ .... 1. ..........
wiring in the building of ' / AKA�r!...�..........................
at.;,..J /.....f .: /.!: j.. .-..... ,North Andover,Mass.
Fee /57,. ......... Lic.N2
f� �........ fJ... ....f..///��� l�
� �� ELECTCAL INS
RIPECTOR f
Check # ✓//�"1-51
':-" 564 `1
: •
�"o L
/RTH
.
p°RT1y TOWN OVER
°.1- D PERMING
SSACMUS�
This certifies that . . . . . . ��+ . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . . . . . �e .'E D . . . . . . . .
plumbing in the buildings of . . .R P. t . . . . . . . . . . . . . . . . . . . . . . .
at. . . <.r-. . . . . . . . . . . . T Andover,Andover, Mass.
Fee.—a)7 . .Lic. No.. `�.3 l. . . . . . . -. . . . .. �.._.�
PLUMBING INSPTO
Check # r L'-
7 8 5
'785
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,,MASSACH
U
SETTS
Building LocationC a4l G T/ Date �0 d
Owners Name �N/1��'/7 �Q d�j) Permit#
Type of Occupancy 46601 Amount 2 —
New Renovation Replacement �j Plans Submitted Yes
No
FIXTURES
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Ln x
a
A a a a
s�sB
1SINJOCIR
MFLOat
R 3RDt FIDCR
MELD
51HKj
61HFLOOR
'1 -
91 H FIJoaR ........
4
(Print or type) Check on
Installing Company Name_ C"� �lGj `t� Sd�i1Zr,L 2 Certificate
Core• I c7 Z 3
Address mpi w-' S�
406 Partner.
r
usmess Telephone G b
Firm/Co.
Name of Licensed Plumber:
Insurance Coveraee• Indicate theinsurance coverage by checking the appropriate box:
Liability insurance policyEr Other type of indemnity ❑ Bond
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
Signature Owner ❑ ❑
Agent
I hereby certify that all of the details and information I have s bmitted(o ntemd) ' above application are true and accurate to the
best of my knowledge and that all plumbing work and install ions perfo ed and r Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass u tt Sta u
ing Co e and Chapter 142 of the General Laws.
By:
Lure o License um er
Title Tyke Plumbing License
City/Town /
1cense NUM577, Master Journeyman
APPROVED�ocE usE orrt YEl
901}x: �
I
�lORTIy ,
<< •° •��o TOWN OF NORTH ANDOVER
A PERMIT FOR PLUMBING
F o +a
,SSACHUS�
This certifies that
CO1 t
has permission to perform . . .vt.tkw . . . . . . . . . . . .
plumbing in the buildings of . . . \-k,�, %.•. . . . . . . . . . . .
at . . . 14.S-. . (r P. s L .T. . .� cv�. . . . . . . . . . . ., North Andover, Mass.
Fee 3 G.:UJ. .Lic. No..I. `t ,Y . . . . . .�. . . . . . . . . .
PLUMBING IN OR
Check # L(s 3
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: MA. Date: - 01 - 010 Permit# .
Building Location: ke f L H
Owners Name:_ Y,?e l keo
Type of Occupancy: Commercial ❑ Educational❑ Industrial ❑ Institutional ❑ Residential
New:W Alteration: ❑ Renovation:@- Replacement: ❑ Plans Submitted: Yes❑ No❑
I
FIXTURES
Lu co
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m = O W W L) H O= W w
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In
O W X W U) :a Q Q m W O Z O f l'- H > Z F-LU 2 v\
V o o LL L7 t9 = _ W H > > > i,-
OIL
SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3m-FLOOR
4 FLOOR a
-im FLOOR
6 FLOOR
7 THFLOOR
8 FLOOR
� . Check One Only Certificate#Installin Company Name: uv-S-cSS �
s
.Corporation S
Address:_ alb Are,,4d/ City/Town: TZ")Sy1ey0 t -)
State:
❑Partnership
BusinessTel:`�'79 - �I S - 7�6 3 Fax: x'28 -�Y3' a//c)
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: /1'L
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes fi� No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ZR Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent
Owner ❑ Agent ❑
By checking this hitbox❑;I 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 will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
Plumber
Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
®-Master
City/rows []journeyman License Number:
APPROVED OFFICE USE ONLY El LP Installer
4 _ Official Use nl
Commonwealth of Massae usetts ���
Department of Fire Se ices Permit No.
Occupancy and Fee Checked '�_
��� BOARD OF FIRE PREVENTION EGULATIONS [Rev. 11/99] leave blank
APPLICATION FOR PERM TO PERFORM ELECTRICAL WORK
All work to be performed in accordance ith the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK ORT PE L I A ION) Date: — �--�
City or Town o . To the Inspector of Wires.
By this application the undersign6d gives n ice of hiq or her intenti n to perform the electrical work described below.
Location(Street&N be
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes..❑ _ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No. of Meters
Number of Feeders and Ampacity ,
Location and Nature of Proposed Electrical Work: Installation of Security system
Cont letion of the following table maybe 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
Above ❑ In- ❑ o.o Emergency ig mg
No.of Lighting Fixtures Swimming Pool arn.4 rnd. Batte 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. Total No.of Alerting Devices
Tons g
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.o 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 ❑ BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: o (When required by municipal policy.)
Work to Start: --" 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: Secur-ity Services LIC.NO.: 1 req(
Licensee: John S. Bassett Signature LIC.NO.: 1533C
(If applicable, enter"exempt"in the license number line) Bus.Tel.No.: 603 594 S928
Address: Alt.Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Lie.9fisee 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: $ �,