HomeMy WebLinkAboutMiscellaneous - 485 WOOD LANE 4/30/2018J
Location -WS
No. CY Date O ^ / - o
. N -TM . TOWN OF NORTH ANDOVER
Certificate of Occupancy $
,SSACMUSE� Building/Frame Permit Fee $—
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 0
Check #
18456 c
Building Inspector
is
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:
DATE ISSUED:
SIGNATURE:
C
Building Commissioner/IngNector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map umber Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54)
Public ❑ Private ❑ Zone
1.5. Flood Zone Information:
Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Vrin'tj
Address for Service:
Signature
Telephone
2. 20 O
i er of Record:
ip4z1& &&
arae Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature
Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
'C
Not Applicable ❑
r�
Registration Num
mpany Name
�
Address
' -4a
OC
Expiration Date--�--
St a
Telephone
SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 & 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work(check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
O)'ICIAL USE ONLY
K.. ..
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
l.� �✓
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH DING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
65
Si ature of Own A ent Date
7'si.R.+A
NO. OF STORIES SIZE
BASEMENT OR SLAB
RD
SIZE OF FLOOR TINMERS 1 2 3
SPAN
DINIENSIONS OF SILLS
DMIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
1�
.ine Lummuriweuccrt uj lY1uJ3ul./1u3rtta
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
n L.1 n 1 / e _
Name (Business/Organization/lndividual):
Address:
001,t 9r 01
City/State/Zip:///. A ge,_- a/ el #: ?.-7 r O/cq ,V yQ/�
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. [:11 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required. ]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required I If
have hired the sub -contractors
listed on the attached sheet. $
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
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.❑ Electrical repairs or additions
11.0 Plumbing 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 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
iContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the.policy and job site
information.
Insurance Company Name: /U erl
Policy It or Self -ins. Lic. #: ('� �% �� ��L::K Expiration Date:
Job Site Address: zzf ®D c/ /0s?:n_ City/State/Zip:z��
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 maybe forwarded to the Office of
Investigations of the DIA.for insurance cover�age_venfication.
I do hereby certify under the pains and penalties of perjury t hat the information provided above is true and correct
Phone #: ` Pl co V 0/, 4
Oficial use only. Do not write in this area, to be completed by city or town official.
City or Town: PermitlLicense #
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 #:
i for ation ata 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, parmersbip, 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 fesides.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 oprate 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
reouirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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. 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 pernut/license number which will be used as a reference number. In addition, an applicant
that must submit multiple penr it/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
Fax # 617-727-7749
tevised 5-26-05 www.mass.gov/dia
REPAIR 0 CASTRICONE CONSTRUCTION LLC FREE ESTIMATES
f
_. CASTRICONE ROOFING & SIDING CO.
Telephone: (978) 682-4266 • Fax: (978) 794-0910
MARIO CASTRICONE • DAVID MICAL
P.O. Box 441, North Andover, Mass. 01845
I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all
necessary materials, labor and workmanship, to install, construct and place the improvements according to the following
specifications, terms, and conditions, on premises below described:
Owner's Name ,
....� ..................................... ..
Job Address ... L L . ............... City. ll/ ........ State
SPECIFICATIONS
.. .,. ..
...............
......................................................
...................
.................... .... z -� .......................
-�o ......................
............ .......................................................
... 4�- .. 4:;1!!; . .......................................................
Materials and labor to cost $ . c�c�Q� .... Pa able . ,
Y .. .. ..and balance in . ..... .
monthly installments of $ ........ , . , each, payable on ....... , day of each and every month thereafter until paid
in full (. . . . . . % charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
Contractor will do all of said work in a good workmanlike manner. Workmanship is warranted for one year.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a
completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid
immediately due and payable. It is agreed that if permitted by law, contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in
addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of
the parties.
The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s).
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract
dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all
parties.
Cover attic storage cleaning not included. Not responsible for ice back up, Not responsible for broken plants or rip-offs.
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the
contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and
understandings of said parties are contained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in operation. : Q
IN WITNESS WHEREOF, the panties have hereunto signed their names this , . , .7 . , , , davof . L'L`f.YL�-c 20
Accepted: Signed ...... ..... ..... .
O er
(OWNER HAS 3 DAYS IN WHICHT3 CANCEL CONTRACT) Signed . . . , , , , , -
Owner
0
Per . ,/�...... St ned . . ... . . . . .
Represon ive 9
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SACHUS
Date. -.' 1.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .. 4 ( C. 4 .............................
has permission to perform . . .. .7 .......................
plumbing in the buildings of ...P.`"- ......................
at .... ........... , North Andover, Mass.
Fee.�..).-! Lic. No.. X7' ...... .... . ........
U-MBING INSPECTOR
Check #
5718
1)10,
I &
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print
/or Type)
JYO r Mass. Date3 Permit #-L7 %
/}
Building Locatioi Owner's Name /
Type of Occupancy RESIDENTIAL
New ❑ Renovation ❑ Replacement :J Plans Submitted: - Yes ❑ No ❑
EMERGENCY RENTAL WATER
HFIXTURES
HEATER ER REPLACEMENT
SUa—BSMT.
BASEMENT
IST FLOOR
2ND FLOOR
3RD
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name WELCH BROTHERS CO. INC
Address 148A TANNER ST
LOWELL MA 01852
Business Telephone 978 453-2100
Name of Licensed Plumber THOMAS F. CAREY
N
Check one:
1�7 Corporation
❑ Partnership
❑ Firm/Co.
Certificate
1501—C
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 7�J No ❑
If you have checked res, please indicate the type coverage by checking the appropriate box.
A liability insurance policy CX 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or [ Owner ❑ Agent avnar'c e�o„r 9 ❑
nereoy cenny that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed a permit issued this plication will be in compliance with all
Pertinent provisions of the Massachusetts State Plumbing Code and Cha 142 of the G r aw .
A
Title
Signature o umber
City/Town Type of License: Master [N Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number 8481
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Installing Company Name WELCH BROTHERS CO. INC
Address 148A TANNER ST
LOWELL MA 01852
Business Telephone 978 453-2100
Name of Licensed Plumber THOMAS F. CAREY
N
Check one:
1�7 Corporation
❑ Partnership
❑ Firm/Co.
Certificate
1501—C
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 7�J No ❑
If you have checked res, please indicate the type coverage by checking the appropriate box.
A liability insurance policy CX 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or [ Owner ❑ Agent avnar'c e�o„r 9 ❑
nereoy cenny that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed a permit issued this plication will be in compliance with all
Pertinent provisions of the Massachusetts State Plumbing Code and Cha 142 of the G r aw .
A
Title
Signature o umber
City/Town Type of License: Master [N Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number 8481
Date . 9... .........
....... /CP
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ...... D, ....................................................................................
has permission to perform4 ... ............. ... .....
..............................................
wiringin the building of .... ......................................................................
2
at ........ ..
........................... .........C.,'.rl..
........... . North Andover, Mass.
....................... .Fei-2'/)Lic. ....... ...............
EI EcrRicAL INSPECTOR
Check #
4711
TUE COAMONWEALTHOFMASSAC SETTS Office Use only
DEPARTARMOFPUBIlCSAF Permit No.
BOARDOFFMPREVEN770NREG ONS527CM12.M
Occupancy & Fees Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat • 0
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) q ff,S 1J00c( co A -L
Owner or Tenant li p 144"
Owner's Address
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes M No 12" (Check Appropriate Box)
Purpose of Building
Existing Service Amps / _Volts
New Service Amps / Volts
Utility Authorization No.
Overhead Underground M
Overhead Underground
No. of Meters
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work W t 2�0t4 InIC Ate Min f Edi af�tZtc � l �.0 T n�
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
F1
Generators
KVA
ground
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local ❑ Municipal
_
Othe
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER•
InSulaticeCoWfage; Ptust�tittotheregttite;rlailsofMas�ctnls�tsGenaalIaws
IbawaaeriLiabffityLwm=PblicyinckidmComplete Coveragecritss alegwvalert YES NO
IbavestlbTMedvandprafofm-etothe Office. YES r -T ffyouhavedmkedYES, plepwiri lethetypeofcoveageby
checkingthe box L ---A
INSURANCE BOND OTHER [2r (PleaseSpegfy> &)91&;h4 -Z •.%2 dfc
DorationDale
rsturlatedValueofFlecwcalWotk $
WO&0Statt h>SpecfionDateRaN-,kd Rough Final
Signet] underlie Rrdlies ofperjury.
FIRMNAME Joe l°'! • "e-10 LiameNo. JV9-VP
te
licffwpl Licer>seNo
Bus rmTel .
e ya otll SA At Tel. No.
OWNER'S INSURANCE WAIVER; lam aware that the Lime does nothave the ma rar>ce- coverage orits gbft ial equivalent as mqutted byMassaVhusetts Gertaal Laws
and that my signattue on thispetnut application waives this wquuzrnenL
(Please check one) Owner Agent
Telephone No. PERMIT FEE $
Signature of Uwner or Agent
Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name: ,
Address
City: Phone #:
Insurance. Co. Policv #
k
Address
City: Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' imprisonment-as_v�ell_as_civil.penattiesin thelmn-d a -STOP W-ORK.ORDER.and_a.fine-of.($1—OOM)-ajtayagainsi.me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby certify under the pains and penalties of perjury that the information provided above is true and correct �
Signature Date
J
Print name Pbone.#
Official use only do not write in this area to be completed by city or town officiar
City or Town L` * Permd/Licensing
D Building Dept
❑Check if immediate response is required .[] Licensing Board
E] Selectman's Office
,'Contact persona -Phone Ik E] Health Department
E] Other
No -
Date ....../ � !
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that f 5 e
..D............................F...........`......................
has permission to perform . �Q {{
wiring in the building of ....... e. .........................................................
at
�_ �, �C•�� �.:........... .North Andover Mass
Fee. vU Lic. No. 1.7./5(. ......
......:......... - <.......r .......:...........
ELECTRICAL INSPECTOR
Check # � . +J/f/
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Commonwealth of Massachusetts officiai U= only
UtN
- Department of Fire Services Permit No.
BOARD OF FIRE PREVEIIII REGULATIONS Oapaat.7mdF=Cbeked
(Rev 11/991 ciw bbl
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
all work to be pmformed in wand ce mith the M=ch=m Eieerieal Code (MEcI CMR 12
(PLEASE PIOI.ININKORTYP ORMATIOIVJ Date~- i A A I o
City or Town o To the Inspector of Wir
By this application the undczsgted gives notice or be a to perform the eiectical wmic described below.
Location (Street &Numb
Owner or Tenant Tcicphonc Na d 79 jo
Owner's Address
Is this permit in conjunction with a building permit -9 Yes ❑ No (Check ApprnpriateBox)
Purpose of Building Utility Authorization Na
Existing Service Amps / Volts Ovencczd ❑ Undgrd ❑ Na of Meters
Nese= Amps I Vohs Overhead ❑ Undgrd ❑ Na of Meters
Number of Feeders and Ampacity
Location and Nature of Prnposed Electrical Work•. /'l rn „ ran
r
Comcierion of the foiiowinc taaie mc,,6e wc;Ver TI u;e :rhe_: of hire:.
Na. of Recessed Flxmres No. of Car -Soso. addle Fans Na of
(Paddle) Tow
Trancinrn..� vz; ,
A
INo. of Lighting Outlets INo. of HotTubs
IGeaa-aton KVA
No. of Li;hting F'iztures o Abovc
Swimming Pool ;��
❑. ln-
C +Battery
0.01 LMC. b::ICy U-nunb
�rnd
units
No. of Receptacle Outlets INo. of 09 Burners
FM ALARMS Ilia. of Zones
Na of Sivitches INo.
of Gas Burners
No. of Dctc :ion and
Initiating Dories
No. of Ranges �No. of Air Cond.
To Tons
g Na of Alerting Dc5lces
No. of Waste Disposers Ilfat
Pip I Number Tons I KW
No. of Scif ont:.ined
TOels: ►
Detection/Alerting Devices
No. of Dishwashers ISpac&AreaHeatin; KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
(Heating. Apprmncar
�-W
ecunry Systems:
a o ater
Beaters KW
o o
No. of
Na of Deyimxs or Eauivalent
Data Winn;
Signs
Ballasts
Na of Devices or Eat:irrt� t
No. Hydromassage BathtubsINa
of Motors
Total gp
Telecommunications Wiring:
Na of Devices or Eaub,alent
INSURANCE COVERAGE: Unless waived Auadi additional detaml f desired, or as mzdred by the lnspeaor of ivi=.
by owner no permit for the performanc of t:le=ietl work may issue unless
the licA=s= provides proof of liability insurance 6-indng "completed operation" coverage or its stibstantiai equivalent. The
undersigned c=ifres thatsuch coverage is in forte, and has eshioited proof of same to the permit issuing offim
CIECK ONE: INSURANCE ❑ BOND ❑ OT ❑ (SpI
Estimated value of ectriacai Wodc $ B (E-qm non �)
t �� by opal policy.)
Work to Start % Inspections to be requested in accordance with NEC Rule 10, and upon completion.
Ica*, under thi pains pamaldes 0fP�lut3', t/motthe inforI on this app&tadon isrrr_tc mmd mmplzm
FIRM NAME: ADT St:t:urity Services DIdol ] is. NH 03049 LIC NO.: 1533C
Licensee: John S. Bassett Signatu C NO.: im3C
(If applicnble. alter "emnpi-in Lite Tc=--numberfne.)
Address: Bus TelNa:-L03 594-5900
OWNER'S INSURANCE WAIVER: Cr
I am aware that the Creaser doer not have the liability ntsurancc covcb-agc n5orm94-5928 ally
required by law. By my signature- below, I hen:by eve this requirement. I am the (check one) (] osvttcr ❑ owner's as:I
Owncr/Agent
Signature Trtrnhn"r Nn PF ANRT Fz z . c 20r—:— 1