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Miscellaneous - 486 WOOD LANE 4/30/2018
10764 Date :. -T),7".. .1� '--'.q ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .................................................... has permission to perform. C'&— 4 bd e'�P' ........... ............ R1.9 -%, -1 ..... y ................................................... plumbing in the buildings of...... ...................................................... 7' at .... 4 .. e�(P ...... W-0-04 ..... L.ft..Ie—k ................... . North Andover, Mass, tl ............................................... Fee '.:P ............ Lic. No. �'41 ..... .......... . b ................. PLUMBING INSPECTOR Check # INTERCEPTOR (INTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES., - WATER PIPING OTHER ti INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [g NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE OF INDEMNITY D BOND 0 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: OWNERF-11 AGENT SIGNATURE OF OWNER OR AGENT ! hereby certify that all of the details and information I have submitted or entered regarding this application are true nd 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 p1' nce wit Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. coT PLUMBER'S NAME L I LICENSE # e SIGNATURE MP U JP 0 CORPORATION RJ PARTNERSHIP P# #= LLC COMPANY NAME ; ADDRESS :>S7 -41 ':511 _1 CITY _! STATE �� ZIP ( TEL Jam/ I FAXCELL EMAIL - -- - -- ----- - -- -- --- - -- -- -- ---- - - - - -- - � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE ( PERMIT # JOBSITE ADDRESS _ OWNER'S NAME POWNER ADDRESS TEL JIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES 0 NO]f FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ i _ - _ __-_ E DEDICATED GREASE SYSTEM ___ 4 _.____I (_______.1 _. 1 � _-__.--� f [ DEDICATED GRAY WATER SYSTEM [ - i _ [ - __J1 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FI nOR / ARFA npAIN INTERCEPTOR (INTE KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES., - WATER PIPING OTHER ti INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [g NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE OF INDEMNITY D BOND 0 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: OWNERF-11 AGENT SIGNATURE OF OWNER OR AGENT ! hereby certify that all of the details and information I have submitted or entered regarding this application are true nd 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 p1' nce wit Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. coT PLUMBER'S NAME L I LICENSE # e SIGNATURE MP U JP 0 CORPORATION RJ PARTNERSHIP P# #= LLC COMPANY NAME ; ADDRESS :>S7 -41 ':511 _1 CITY _! STATE �� ZIP ( TEL Jam/ I FAXCELL EMAIL - -- - -- ----- - -- -- --- - -- -- -- ---- - - - - -- - � ui w LL Y. I .N The Commonwealth of Massachasetts Department oflnrius€riglAccMiks Office oflnvestigations 600 Washington Street .Boston, MA 02111 www.mass.gov/ciia Workers' Compensation Insurance Affidavit: Builders/Confractors/Elc A.ppReant Wormation Name (Businosiorgauizaiion/.individual): % Address: �. S CitylstatelZip: Are you an employer? Check the appropriate box: 'Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. F1 New c6nstruction employees (fall and/or part-time).* have hired the sub -contractors 2. KJ am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling ship and'have no.employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance S. ❑ We are a corporation and its officers have exercised.their 10.❑ Electrical repairs or additions required.] 3.E1 I am a homeowner doing all work right of exemption. per MGL 11. [] Plumbing repairs or additions myself. o workers' comp. c. 152, §1(4), and we have no y [N p 12.❑ Roofrepairs insusancerequired.] employees. [No workers' 110 Other comp. insurance required.] ,!Any applicant that checks box#I must also M out the section bel6w showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they 9 e. doing all work and then hire outside contractors must submit a new affidavit indicafiug such. ?'Contractors that cheokthis box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site Nformadon. Insurance Company Name; Policy # or Self -ins. UG.. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requixeduuder Section 25A ofMGL 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 p enalties 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 o£ Investigations of the DIA for insurance coverage verification. Ido hereby ce ,aiyder thepoiq andpenalties gfperjury Aat the information provided above is true and Correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other II Contact Person: Phone M JI Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,• express orimplied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the Foregoing engaged in a joint enterprise, and including the legal representatives of a- deceased employer,or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant of the. dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shallnot because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local lie -ening agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill. out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phonenumber(s) along with theircextrficate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to cant' workers' compensation insurance. If au LLC or LLP does have employees, a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for coniumation 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 he. ` City or Town Officials Please be sure that the affidavit is complete andprinted 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 inthe permit/license number which will be used as a reference number, In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or towb)" Acopy 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 -lion 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 eta.) said person is NOT required to complete this affidavit. The Office of lnvest gations would like to thank you in advance for your cooperation and should you have any ciuestions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho CQmmoaw. oalth ofYbuacl?v. atP Doparbunt Qcfkadustdal .Accxdento Office ofJavestiv lona 6,00 Waftg m Street Boston,, UA 02111 Tel, # 617-7.27.4900 QA 406 Qx 1:-g77- MASS Revised 5-26-05 Fax 61 7-727'7F749 ' ��41:5a!�e�jYvt ?da Date�.:1... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that.........................................:........�2 ...r`,(P........................................................ has permission for gas 'nstallation .... ....................................................... inthe buildings of ....... 1 ! ............................................................................... , at ....... 1.1k ...... WZ? ?c ............................................. North Andover, Mass. Fee c e0...... Lic. No. �3`}`a............................................................. GAS INSPECTOR Check # I/- q I 1 9553 FRYOLATOR FURNACE GENERATOR Ir GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN L - POOL HEATER r d ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER...... . . . .............. ........ . ........ . ...... .. ... .... ... . ... .... . .... I L --j INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JAI NO 0 I tF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 4 OTHER TYPE INDEMNITY 0 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: OWNERF--]AGENT E] SIGNATURE OF OWNER OR AGENT 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 y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co pl, /ce ' h all,�qrtinent pro sl of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %j PLUMBER-GASFITTER NAME LICENSE# --S'IGNATURqw MP 0—MGF 0 JP [I JGF [I LPGI CORPORATION F1# = PARTNERSHIP [J# LLC El# COMPANY NAME: 1=6ig JL�ZADDRESS j CITY Z/ STATE ZIP TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A-. MA DATE I PERMIT# JOBSITE ADDRESS. L . . . . �OWNER'S NAME OWNER ADDRESS 11 TELF FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL RESIDENTIAL4 CLEARLY I NEW:E3 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR Ir GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN L - POOL HEATER r d ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER...... . . . .............. ........ . ........ . ...... .. ... .... ... . ... .... . .... I L --j INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JAI NO 0 I tF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 4 OTHER TYPE INDEMNITY 0 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: OWNERF--]AGENT E] SIGNATURE OF OWNER OR AGENT 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 y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co pl, /ce ' h all,�qrtinent pro sl of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %j PLUMBER-GASFITTER NAME LICENSE# --S'IGNATURqw MP 0—MGF 0 JP [I JGF [I LPGI CORPORATION F1# = PARTNERSHIP [J# LLC El# COMPANY NAME: 1=6ig JL�ZADDRESS j CITY Z/ STATE ZIP TEL FAX CELL EMAIL I. w � 4 O z 0 H U W a w . . . . . . . . . . . . . . . . .. . o r] a z . Oz F] W � W H a Z w co < w W� o W O ui > w w w a) a z a a a � U �y J ' F °- a Q T w R LL W 0 H U W a C�7 I. ,� M S s i�u::;C`(iMMaAI�A/C"l�'� Ti L .. � _ _ _.._ ._..... ',... ..., 1�5��a.�c� ��// Inspectional Services Loi M -T -W-T- F - S - S INSPECTOR: JB BL PM DD SG )ATE: / /2013 Permit # Address/ Name INSP.-TYPE PASS FAIL Inspection notes 7:00 AM OFFICE 7:30 AM OFFICE a, q ;b'0 AM OFFICE . e 8:30 AM OFFICE 9:00 AM OFFICE 9:30 AM OFFICE ' 10:00 AM pp E� 10:30 AM 11:00 AM t i' Ell 11:30 AM 12:00 PM 44LQtl i7 12:30 PM'LLL%41- Ali 1:00 PM .1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM - ' ):00 PM + :omments / Notes: Date... ! ).00 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... Ahl.q /- � ..P C. has permission to perform ..............S ...... 6 .... .77y ....... wiring in the buildinqpf ............. 41 ...................................... ""k at .... W b ... t4q P ....................... North Andover, Mass. Fee Lic. No.10C. ELECTRICAL INSPECTOR Ll Check# 6C/ -7 10723 l.ommonwealth o�aslac�ude Official Use Only e1JeParfinenf o� }ire Jerucce� Permit No. /07J9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank 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 ORTYPEALLINFOTION) Date: � � ! I.; AZ City or Town of: C&W-6- 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) Mo UJ poA Owner or Tenant Telephone No. `1 f 6 "(00?)-� I f6 --- Owner's Addressj(Y`Q Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Bog) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ a Number of Feeders and Ampacity No. of Meters No. of Meters ,Location and Nature of Proposed Electrical Work: Install residential security system No. of Recessed Luminaires vrvsri No. of Ceil.-Susp. (Paddle) Fans su— muy ue waivea uy ineinspector o Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool bove ❑ In -No. rnd. Zrnd. of Emergency LighTlEg Battea Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o,Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat nip Totals: Nam er __.__..____...___.._._._____ Tons KW _ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ -Municipal ❑ Other No. of Dryers No. o Water Heaters KW Heating Appliances KW No. of o. of Signs Ballasts Security ystems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommumcahons u ing: V. of Devices or uivalent OTHER: Attacn aaa:ttonat detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrial Work: 540D en required by municipal policy.) Work to Start: 3 1 I 'Z- 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 ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: Nightwatch Protection, Inc. LIC. NO.: 7 0 2 4 C Licensee: Paul DelSignor SignatureFA.af I'd � IC. NO.: 7024C (If applicable, enter "exempt " in the license number line.) us. Tel. No..888-722-9282 Address: 22 Briarwood Drive, Westford, MA 01886 Alt. Tel. No.• *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. .7 SS000000969 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. $ �S,QQ The Commonwealth of Massachusetts Department of Industrial Accidents 'n Office of Investigations 600 Washington Street Boston, Mass 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual) Address:-�) D A - w 2 (� -D r 9 City/State/Zip: JaLI M, %% () 30 T - Phone#: 998- Are 98- Are you an employer? Check the appropriate box: l ./ ' I am an employer with _ j 5 4. ❑ I am a general contractor and I employees (full and/or part time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have a working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. t required] 5.0 We are a corporation and its 3. ❑l I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § ](4), and we have no employees. [no workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. 0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.0ther_ f_ �� ( S`iSJ�M �_0 w \1ut4f,,g C 'Any applicant that checks box #1 most also fill out the section below showing their workers' compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContactors that check this box most attach an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have tmployees, they must provide their workers' comp. policy number. lam an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. + /� I Insurance Company Name:kay4w_A ILLY 1 S . 1..b . () 4U_ /Il � J u_cS Policy # or Self -ins. Lic. #: 3 Cp W (--� & a w � � CJ �p Expiration Job Site Address: I � G (")008 1C _ City/State/Zip;AkA_� 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 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 foam of a STOP WORK ORDER and a fine of . $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains andpenalties ofperjury that the information provided above is true and correct Date: 2 Print Name: ��AL ( LJ�i�_ _ Phone#: 888 - t Co a _ UV_z Oficial 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): j 1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: Date ..-)..0 . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... /! Ir . ".. .............. has permission to perform ... 1.C, !............... plumbing in the buildings of ................ at ... U. If .................... . North Andover, Mass. Fee. Lic. No. ...�:,........, :....... . PLUMBING INTOR Check r 5 9 19 MASSACHUSETTS UNIFORM APPLICATI (Type or print) NORTH ANDOVER, MASSACliUSETTS n ,� Building Location r ti a 06' Owners Name FOR PERMIT TO DO PLUMBING f Date /I 14141'Permit # ,�� l 9 Amount Type of Occupancy 7��� New ri Renovation 0 Replacement 1:1 Plans Submitted Yes E] No ❑ FTU.11RES r • i EMU (Print or type) r �% t Check one: Installing Company Name /' r �sJ�Ci�letE� �� ❑ Corp. T nPartner. " Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the e of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Certificate 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 11 I hereby certify 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 under Permit Issued fj this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' Code C ter f the General Laws. By Signature ol 1-1censeci Fluper Type of Plumbing Li ense Title >,`? S City/Town 1L se um er Master ❑ Journeyman APPROVED (OFFICE USE ONLY N Location �3 No. `i 91 Date I GL-) o MORTh TOWN OF NORTH ANDOVER .. 9 Certificate of Occupancy $ O CwuSP� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 y Check # OA S 4 17031 M 11 t C,, i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �c„R BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: ✓ ' � " Building CommissionerflEgwor of Buildings Date SECTION 1- SITE INFORMATION ' 1.1 Property Address: ��& Woos L/}ne 1.2 Assessors Map and Parcel Number: 2--2- .ZNJ Number Parcel Number Nof� A pi(, lover, / ( M�;Pp 1.3 Zoning Information: Zoning Diarict 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 Nater Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 ZOIIe Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record / M I-Ch�e d J(A e RkhIC4Arl v Wo�P L flNe are (Print) Address for Service: /�/ 41 7. Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 0 Signature Telephone SECTION 3 - CONSTRUCTION SERVICES A Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone z M 91 to m r M r r a� .9+ SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) 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 .......0 No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building X Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: yy/ — - -� -Q ✓bt U�(�, I - — '� � (h f Uv SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant. OFFICIAL USE ONLY x Building 3 zod i (a) Building Permit Fee Multiplier 2 Electrical � 6o (b) Estimated Total Cost of Construction 3 Plumbing S60 Building Permit fee (a) X (b) 2 �� c7 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number C� SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, I C hot T, RLk n I(AA ® as Owner/Authorized Agent of subject property ereby 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR Tl1VIBERS 1 ST 2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS 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 t� r t C North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: M/4 Tran ffcr SYv J/1 (Location of Facility) Signature of Permit Applicant oy Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector O M M cd i5 o c c � z m c aOH � c W O o , pr. A G ro Uw J QC :RCc a�' in w V W °D v w C7 '� n�' w FL °' rA o z cin Q v cE FM - c c m c c _O y C C3 V J QC :RCc m G. 0�1 0 E c a: om c mc E I: CO �y y yCD cm O y CA O O - 44 4y CA d O Sti O C13 G W 0� cm H m W C W r.+ W C Z P ' E C e0 -. ca mw vi cm o co ®:e p$ O !'� $ 0 go > .i Vq§ h M. CL O CD Q _m' CL. CA O v h O cc C _cc y w cc Date..�1- �..'.' ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.v`.............t.�".1`........:.................................., has permission to perform wiring in the building of671 ............................................................... at ..1: / .'.':.......Z:r..`.'.....`...... "�-^ .............. . North Andover, Mass. �ELEGTRICAL INSPECTOR Check # 2 �/ (f J TRE COMMOI 'WEALTHOFMASSACHUSEM DEPART3I1AT0FPUBHCS4FETY BOARDOFFIREPREVEN770NREGUTA770NSg7CMRI2M Office Use of Permit No. --41,41'351 i Occupancy & Fees Checked APPLICA77ONFOR PERMIT TO PERFOW 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) Date o 3 Town of North Andover To the Inspector c The undersigned applies for a permit to perform e electrical ctrical work described below. Location (Street & Number) (,J p p b C o Q Owner or Tenant Ma Mcg „� �,,'O k, x ] " Owner's Address t:5 S ✓", i Is this permit in conjunction with a building permit: Purpose of Building Key) dell �1 0-,1 Existing Service 10 © Amps 110 /240 Volts New Service vC"3 Amps IZo /240 Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work _6a1r- No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets No. of Switch Outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters No. Hydro Massage Tubs OTHER- No. of Hot Tubs Yes M No Swimming Pool Above of Oil Burners 2Sg - �, (Check Appropriate Box) Utility Authorization No Overhead tt� Underground .� No. of Meters Overhead Underground No. of Meters L No. of Transformers To K1 Below �--••f Generators K` No. of Emergency Lighting Battery Units No. of Gas Bunters _ apwalat No. of Air Cond. Total `� y /0. FIRE ALARMS No. of Zones Tons aVa>vew� $, r , No. of Heat TotalTotal 3C(5! No. of Detection and Pum s Tons KW Initiating Devices Space Area Heating KW No. of Sounding, Devices - OWNER'SIlISURANCEWANERIamawarethattheLicer doesriothavetheinstuar>cecorerageoritssut�tiagmval astagtmedbyMass�GeneralLaws nd that my signahueon thispeirntapplication waives this mqufternent No. of Self Contained Please check one) Owner ® Agent Detection/Sounding Devices Heating Devices r PERMIT FEE $ KW LocalMunicipal Other M Connections KW No. of No. of Signs Bailasis No. of Motors Total HP h>St==CovTdff-- Patst�anttotherat r rYsofMassadir> IsGalaalLaws Ihawaar tlnbtlitylnua- =Pbhc7'a>chliMc.ornpletE ODNearonls >bstada apwalat Iha,&wb n tedvabdproofofsametatheOffice. YES [—TP if3ouba%edleckedYFS,plminc6 &ftt ype°fo°ver`tgzbY d>etrgthe _ box L�.1 Bolam `� y /0. w(Xk to sW ` .1 v_3 E Rmffi aVa>vew� $, r Signeaunderl;�%;A;ofpesjt> Q r MI'c h tre �)CJr°d FIRMNAME 1 e 3C(5! MI Q loensee c� P I��� ► S;gnattae lieNo P %drhPss�r,l BtTelNo: At<Tel 1% % J OWNER'SIlISURANCEWANERIamawarethattheLicer doesriothavetheinstuar>cecorerageoritssut�tiagmval astagtmedbyMass�GeneralLaws nd that my signahueon thispeirntapplication waives this mqufternent Please check one) Owner ® Agent W Telephone No. r PERMIT FEE $ Signature o caner or gen The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print r Name: 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. Comnanv name: Address City. Phone* Insurance. Co. Policti#_- - ----- Company name: Address City: Phone#: f - 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 $1,;Gz and/or one years' imprisonment-as_well_as_civil.Renaftiesin-theinrm4-a-STOP.W-ORK.ORD,ERand_a.fine_af..($IDO.DD)-a day.against.me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# �a Official use only do not write in this area to be completed by city or town official'. City or Town Permit;Rkensinct r Building Dept []Check if immediate response is required Licensing Boar p Selectman's 0 Contact person: Phone #. Health Departn F, Other Location Zl4�, —/�� No. 4-10,1 Date /Z- -14 ,.ORTH TOWN OF NORTH ANDOVER 0��.•, :• ,b0 • _ • OC .. A Certificate of Occupancy $ ,SSAAre. CNUSEt'�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 5) Check # '7/ 6 11,53 Building Inspec TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING s�i (f€i+La Use "i BUILDING PERMIT NUMBER: f DATE ISSUED: C C SIGNATURE: BuilFn ommissioner/In Date.�ector of SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Z� Map Number Parcel Number `4C.J ICS � � 1 V J �� ►mac c 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lot Areas Fronta e 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) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: _ Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Oicensed Construction Supervisor: e-1-2 License Number �� R) i Address / J, 3 0— 4, r DC.—'X Expiration Date *,atre Telephone 3.2 Registered Home Contractor Not Applicable ❑ Improvement 2R / L`4_(I b /-} tel ? � .— Comzopany Name PRegistration O �, 2 Number Address _ l J Expiration Date Si nature Telephone Ma M Z O W SECTION 4 - WORKERS COMPENSATION (XG.L. C 152 § 25c(6) P0. 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 Descri tion of Proposed Work check allapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: }-e- Z K _&t_- e4 rgi 1 6e'� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated CostDollar ( ) to be Completed by permit applicant tiFFICIAI(. USEeONLY . 1. Building, �—� DO® (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) a(�_ �- 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 BUILDING PERMIT I,, lt`EEL i IKE Qb►/4 fes! as Authorized Agent of subject property Hereby autho ' e to act on My hall, i 11 atters r 1 ve work auto ' ed y t is ilding permit applicai � /J ,Ll/ ' (JC) a ':� Si ature of O er CI Date SE TION 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 Signature of Owner/A ent Date _ - NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 Sr2ND 3RD SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS 1thIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE c 19 su NU00 Ck FORM - U - LOT RELEASE FORM . i t , `° 2� INSTRUCTIONS: This form is used to verify that allnecessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. I..............M.........■■........................r.....■ ■.,.■ ..moon...■ APPLICANT �Y C (U Bob- 600 —c!3 ly ASSESSORS MAP NUMBER O -OL LOT NUMBER 2 C) LOT NUMBER STET (,e�00 J--d}-fL S STREET NUMBER ................................n.n........o■.........,...................■ OFFICIAL USE ONLY ..........................................,............................,..... RECONUvIENDATIONS OF TOWN AGENTS ..P.O. I 02 rJ CONSERVATION ADMINIS OR DATE REJECTED CONDAENTS CONIMENFS RECEIVED BY BUILDING INSPECTOR DATE APPROVED TOWN PLANNER DATE REJECTED CON 4ENTS DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON MENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERWr DATE APPROVED FIRE DEPARTNvIENT DATE REJECTED CONIMENFS RECEIVED BY BUILDING INSPECTOR Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Affidavit Please Print i am a nomeowner perrormmg an wont myseir. Li I am a sole proprietor and have no one working in any capacity QI am an employer providing workers' compensation for my employees working on this job. Company name. Address City: Phone: Insurance: Co. Policy# Company name: Address Failure to secure coverage as required under Section 25A or MGL 152 can lead tathe kgwftian of t per. of arfrne upF to s t'.51 and/or one Yeats' imprisawnentAS WeRASA 47 Pena YAORKDFMERAAafto-dA$tW.W)-aAdWmgabWm.. understand that a copy of this statement may be forwarded to the office of l� chhe DIA for coverage verojaw t. / db hereby certify wider the pains and" penalties ofpedwy that the irftmraUarprovided above is true and correct Signature pate Print name Plume-# Official use only do not write in this area to be completed by city or town officiar Cdy Wr Town 91 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) di Signature of ermit Applicant 1 ,3q1ii.�.r ;,:;moi NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector FGGI TEREO LAND 5UPV�'0K5 5 h1.AMMONG 5?'P'EET /Qw,Ce5 s tR, MA C l G I C Co•752-��p5 F.qX i ) IYIV1 1 1 \A rl%.04. IF V%J& %-%./ i 1NO,# `N r N, MICHAEL T AND JUUE M RUHLAND m LOCATION 486 WOOD LANE .NOIRTH -&UVIEER, SCALA l " = 20 DATE 9--� 18-03 Qr. nc.n � -Y-W% ��67f 2�9 F,. M OMVOLM 2948 *t evftrr T,r " Aw.0wsc me wr wrs+lli w er+mw�, suoo w►:r+m � ctt s•s>o �: Km + *a w" wwo= ar scat W 6 Mai URCMNV46T A006NI7L IArM, DVM WTK R -MM MW Pim PW= U#Mows W?sl7r N Odr"mo. c"fied to: Mount Vvlarl ktI"qyg�e Corpar-i mr. michgad i . Rui�lond Julia M ftuhlend I WOOL) LANE mmm OSB wiAEw, ws v. emraeL. PC MOM M MWAN n "r TOTAL P,01 W. r Ruliland 11/24/03 Mike Kendall / Ruhland Job 4:01pin No. Andover. MA 1 of 1 Ke%BeamR Version 4.12 Member Data Description: Joist #1 Member Type: Joist Application: Floor Main Joists Lateral Bracing: Continuous Deck Connection: Glued & Nailed Moisture Condition: Dry Building Code: NBC Live Load: 40 psf Deflection Criteria: L/480 live, L/240 total Dead Load: 10 psf Filename : Joist #1 DOL: 100% 21 6 0 21 6 0 Bearings and Reactions Input Minimum Worst Case Location Type Width Length Total 100% Dead Total 1 0' .00" Wall 5.50" 1.75" 519# 519# 415plf 104plf 519plf 2 20'8.75" Wall 5.50" 1.75" 519# 519# 415plf 104plf 519plf Design spans 20' 8.75" FE'roduct: IB 600 11 7/8" 12.0" 0.c. Allowable Stress Design Actual Allowable Capacity Location Loading Moment 2686.'# 4635.'# 57% 10.36' Total load 100% Shear 518.# 1420.# 36% 0' Total load 100% End Reaction 518.# 1420.# 36% 20.73' Dead load LL Deflection .3962" .5182" L/627 10.36' Total load 100% TL Deflection .4953" 1.0365" L/502 10.36' Total load 100% Control: LL Deflection Design assumes a repetitive member use increase in bending stress: 7 % All product names are trademarks of their respective owners Copyright (C)1989-2002 by Keymark Enterprises, Inc. ALL RIGHTS RESERVED. yma k f �,, `* ✓1e {`no�rrmzn�zruea�lr a��.t[,nesac�trselib t f t +,a BOARD OF BUILDING REGULATIONS t License: CONSTRUCTION SUPERVISOR I v; Number: CS 053524 t1 is t f Birthdate: 10/08/1958 _ Expires: 10/08/2005 Tr. no: 9346.0 t Restricted: 00 ` MICHAEL P KENDALL PO BOX 1153, —� GARDNER, MA 01440 Administrator j 0 �r� ✓ize �om�nza�uurrG�l�i of ,�lL�afaclicrdP,i�G. ' -\ Hoard of Bididing HLgolations Intl Standar& HOME IMPROVEMENT CONTRACTOR Registration: 10972.5 Expiration: 9/24/2004 I Type: Individual I MICHAEL P. KENDALL MICHAEL KENDALL PO BOX 1153/ 165 BAKER ST �. GARDNER, MA 01440 , Administrat<:r Cl) m C m C/) 0 m CO) coZ CD ar m m CL _. a� -a .pCD o o p CL Q CD 0 t0 CD /y CD 0 SL•: d CD rF CD y� CD CA co 0 co C c? — c d S O -•H O Q H aO4cm CO) O C2 T ycia� CD Z �� y = m n�O = N C9 O m H p M O Wim' V Z O0 CD to�.� O La. c .� W CD L, C•y :A C-' CL a o = CL vJ m m y : x (n mco 0 c7� :•1 C a COO Ny��/' l"f � N � d p� • \. Q ca it L a f0 CC O .rt 0 CD 0 ® o � Q H C CnCD O r: =d3"a s�Zyo a rkoi . � e � Z MA o d z w 7 (IQ C27 �' 00w r A �^ A. x CD0 CD 0 c Date......... /......f....... ;•t?``�-:'�6 �oTOWN OF NORTH ANDOVER PERMIT FOR WIRING 10 This certifies that .....- ....:::................� • 141 ... -11. . . .......... ......, has permission to perform ` - +� x`Q' ............................................................................... l wiring in the building of at . e/ ....... . ^........................... .. , North Andover, Mass. Fee.)Z')....��... Lic. No. ...1 ............... .......................................... ELECTRICAL INSPECTOR Check # 4972 ?7fg emnrmsw7w 6�7?11.�fSSrgt� ZlS�7`7S DO -4--a 4 pg&- S41ty D OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 vin,iavaC Permit No. Occupancy & Fee Che( APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print In irk or pe all information) Date To the Insp ctor o wires: Town of orth Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number Y/ �t LyoJ L 4,,,e Owner or Tenant Owner's Address Is this permit in conjunction with a Purpose of iuilding pe it Yes b No 0 (Check Appropriate Box) Utility Authorization Existing Service 2U (� Amps ! �U 2 I �% Voits Overhead 0� Undgrnd t No. of Mets New Service Amps Voits Overhead 0 Undgmd a No. of Met( Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Wei,/ wo, C + 6 OTHER: INSURANCE COVERAGE. Pursuant ba the requiremen6ts of Massachusetts General Laws I have a current Liability lnsurance Policy including Completed Operations Coverage or its substantial equivalent ES NO - have submitted valid proof of same to the Office YES = NO - If you t}avlchecked YES pi indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER (Please Specify) ZUr� C- �((TT�� 1 t (Expiration Date) Estimated Value of.Electrical Work$ 2 00c) Work to Start 1171-1 U 4 Inspection Date Resquested Rough Final Signed under the Pe atties of perjury: ( FIRM NAME �tC�gQ s II LIC. NO. fZ 37S r l Q jj Licensee M, C ,- 2 ( USC 8", Q i Signatu LIC. NO. SCI -L C Kee- / Bus. TO No.__J i'� Address 1 Pl n HCl r �I�I / Aft Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Li enses does not have the insurance coverage or its substantial equivalent as required by Mass General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above 0 In 0 No. of Lighting FiDdures Swimmi Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone _ No. of Detection and Total No. of Ra I No of Air Cond Tons Initiating Devices _ Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices _ NoJ of Self Contained No. of Dishwashers SpacelArea Heating KW Detection/Sounding Devices _ 0 Municipal 0 Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant ba the requiremen6ts of Massachusetts General Laws I have a current Liability lnsurance Policy including Completed Operations Coverage or its substantial equivalent ES NO - have submitted valid proof of same to the Office YES = NO - If you t}avlchecked YES pi indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER (Please Specify) ZUr� C- �((TT�� 1 t (Expiration Date) Estimated Value of.Electrical Work$ 2 00c) Work to Start 1171-1 U 4 Inspection Date Resquested Rough Final Signed under the Pe atties of perjury: ( FIRM NAME �tC�gQ s II LIC. NO. fZ 37S r l Q jj Licensee M, C ,- 2 ( USC 8", Q i Signatu LIC. NO. SCI -L C Kee- / Bus. TO No.__J i'� Address 1 Pl n HCl r �I�I / Aft Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Li enses does not have the insurance coverage or its substantial equivalent as required by Mass General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $