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Home My WebLink AboutMiscellaneous - 57 BERKELEY ROAD 4/30/2018 J 57 BERKELEY ROAD / 210/04_ 760000.0 i E i i i i i E Date.(0114112- 9444 f 14112....9444 p•,".��T:'� TOWN OF NORTH ANDOVER PERMIT .FOR PLUMBING { SSAC64US� R This certifies that . . . . . . . . _ .`:�;. . . .. has permission to perform .� . . . .`. . . . . . . :; plumbing in the buil in s of . .J!� 1(.(1 .,E---. . . . . . . . . . . . . . at . . . .�. . . . . . . . . ! . . . . �1!1. . . . . . .. North Andover, Mass. Fee.lZ.,`Z Lic. NA-2-058' . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I MA DATE G _� 1 PERMIT# NO JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS. t 0, _ TEL -- FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: Ell RENOVATION:a- REPLACEMENT:0 PLANS SUBMITTED: YES NOM-1 FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ._..._._1 _[ 1 _._,.._J _-_ ! f 1 ! -__J __. I I l I DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _f ! � I .-.___.J 1 _._..._.I _._.__I _-_-_- .___..._I ..--_-_J.]---- -.J FOOD DISPOSER ! J I 1 -__1 ! 1 ._-___.I FLOOR/AREA DRAIN I 1 _--._J _.-� 1 I 1 [ J ..--.-_._l __._-J INTERCEPTOR(INTERIOR) I .__...__._! i _-_-f ( ( I ------- .-____( __.____1 ------_1 KITCHEN SINK LAVATORY + ___J ._. ._. ---_J ROOF DRAIN SHOWER STALLI SERVICE/MOP SINK TOILET I { -� _ _.E J J � ._- _J _- I _--._! -.-.-J ._ __I _.____I ___-__ __...._{ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I-- I OTHER .__-- I rf = s INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ,-_r NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE T E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND D 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: OWNER 0 AGENT 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 my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl' a wi II Pert' ent pro ' 'on o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME{V d >t �- �(LICENSE# _/ S� NATU MP0"JP 0 CORPORATION 11# PARTNERSHIP 0# j LLC 0# COMPANY NAME �Z7- �BDDRESS CITY �STATE ZIP TEL ��-_� �''�-' y FAX L_e' c_T; CELL �f i .._-t EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No Of THIS APPLICATION SERVES AS THE PERMIT ❑ IF ❑ - /�/� FEE: $ PERMIT# PLAN REVIEW NOTES AL\\ The Commonwealth of Massachusetts Department of industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization)Individual): - - - - . Address:_ -- - City/State/Zip: 6na__®IVhone M � ,•^ ?�j F2!. a3, employer?Check the appropriate box: employer with 4. ❑ I ama general contractor and I Type of project(required):' ees(full and/or part-time).*' have hired the sub-contractors 6. ❑New construction ole proprietor or partner- listed on the attached sheet t 7 ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'com .insurance 5. 9.F. Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑.I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp, c. 152,§1(4),and we have no insurance required.] t employees. [No workers' 12.❑Roof repairs comp.insurance required.] 13.❑Other "Any applicant thet chec:W bo.=.�l m:si also till v'�t the section be�or.shoe*Wb t:^.e wa:�'e�:::y�:saiian poL'cy info.:ration. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'romp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 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 coverage verification. I do hereby certify under p ' s and penalties ofper' ry that the information provided above is true and correct Signature: Date.: Phone#: Off icial use only. Do not write in this area, to be completed by city or town official y or Town: Permit/License# uing Authority(circle one): oard of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector ther Person: Phone#: 0. 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 of hire, express 6r implied,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 not more than-three apartments and who resides therein,or the occupant of the dwelling-house-of.anotherwho_employs persons todo_maintenance,.construction or-repair-work on-such dwelling house-- --- — _ or on the grounds 6r building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,'"5C(6)also states that"every state or local licensing'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 co>inpliance 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-contractor(s)name(s),address(es) and phone number(s)along with their certificates)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 anLLC or LLP does have employees,a policy is required. Be.advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be scare to sign and date the affidavit. The affidavit should t• —3y�:CI.i_ _:i..is being requ'es*ton,not my D epZrtmon or 13�rte•_—ice e=�E_E G_-�or toCtr t11_�-tur Fp p aaCa`sY''F:�rthE=.:et- r tn�s-; F 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 Iegrbly. 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 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations wou-Id'like to thank you in advance f6r 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 Commonweal& of Massachusetts Department:of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. A 617-72.7-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax 4 617-72.7-7749 unwrar m ooc• n1,T; MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) NORTH ANDOVER . Mass. Date ) _ I§uilding Location 5 _A!rkl i/ Permit # 2,1-20 rr Owners, Name /6�W4/ • x _ New '—? Renovation �J Replacement Plans Submitted �] FIXTUP=C N � W N p?O- _ to us N a: W Od W o !t C t4- e = uJ N a W to O W W to j O1 J Z < 2 ed C a W t" W V t7 F• .Z' ►- 2 t.. f• y N m ? O ~ W O to W 2 d W < eC d .W > C W 6 tL d C O O W O W f- Q : O U1 Y 010-11-1 O SUA—t3SIAT. BASEMENT I ST FLOOR G1 2ND FLOOR 3110 FLOOR I 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO. Corp. 2122 Address 5737J/2 SO UNION ST Partner. LAWRENCE , MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter �cr Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: - Liability insurance policy.'. Other type of indemnity Q 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 coverages. Signature of owner/agent of property Owner 0 Agent E I hereby certify that all of the details and InfOrmation I have submitted (or entered)in above application ate true and accurate to the best of my knowtcdge and that aU plumbing work and InicA ations performed under Permit issued fo: this application wiu-be in compliance with all pertl{rent provisions of the Massachusetts State Gas Code and Chapter 14:of the General Laws. •.. By TYPE LICENSE: Plumber �— Title asfitter Sig aEure of Licensed Plumber or Gasfitt;er City/Town: Master Journeyman 9Qfi� APPROVED (OFFICE vsE ONLY) License Number `"'`s"'=;..%r''�F`r`r-`^ -..vr'n+re%n_:':i.�`.;.,� ... ._..",w..��: =vt� -•.:.:z.«.�3s... .»....._ P 1 ATL` 2520 Date.. .4/- . . .: ..... . .q: NORT" TOWN-OF NORTH ANDOVER - - pF 14, 3= �� O PERMIT FOR GAS INSTALLATION p SSACMUSE d I J d /-/ This certifies that . . v.Y.S /� . . . I , , , , , , , , , , , ,g„ has permission for gas installation . . . . . . . . . . . . . . . .. in the buildings of . J-9. ...... . . . . . . . . . . . . . . . . . . . . at . . .3.7 . .U4� r. e. j. . . . . . . .. North Andover, 4s'. Fee. . . . . Lic. No..9. .G/J�3. . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOtDeile f Date. 9532 NpRT". TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� n This certifies that . . . . . . .C. C • • • • • • • • • • • • • • f has permission to perform . . . �. . . . � . . plumbing in the buildings of . 7Z�kka qk, . . . . . . . . . . . . . . . . . . rkl�v sT f' at . . . . .'3. . . . . ...North Andov6r, Mass. Fee Lic. No.. . . . . . . . . PLUMBING INSPECTOR Check „" Su k b MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ,^ � i MA DATE/ /02 _( PERMIT# JOBSITE ADDRESS ,� OWNER'S NAME POWNERADDRESS S I TEL — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL�- PRINT CLEARLY NEW: RENOVATION:EY'REPLACEMENT:Q PLANS SUBMITTED: YES Eq NOF-] FIXTURES'l FLOOR- BSM 1 2 3 J45j 6 7 8 9 10 11 12 13 14 BATHTUB I _# _CROSS CONNECTION DEVICE I i I € # [ i # f # I DEDICATED SPECIAL WASTE SYSTEMDEDICATED GASIOIL/SAND SYSTEM # # I mf _ . ^� .___.._f - _# I ,.�# -.� ( - _I DEDICATED GREASE SYSTEM I --- __.--! -----.--i ( � __---_.-! ..----_-I � —_.I I ----I I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER —====== DRINKING FOUNTAIN ._.__# ___.._1 1 ( f ' --....-' .__-_-! I=== FOOD DISPOSER ---1 .__# _...___# __.__-# ----._.__1 ...-_.._-_i -__..-= FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) -_ f _..-.__._.-# .._._.-._i � ! - # � f i f __,..! ._.__I _I I _..-.__..# KITCHEN SINK --# -3 ----r --( - J ---' - -( -- -! - --I --I --- --4 ----# ! --- LAVATORY --' --!I J-j --- f -- --i ------1 -.----f --- --._1 _ f f - -- ROOF DRAIN I 1 .._– I __-.1 —.i SHOWER STALL SERVICE/MOP SINK TOILET I # ...____I ._-- -__# _.__f _.__.( ___.-.-� -__.___( .___I _-_-__f ..__-_..f ______( .____1 ...__...___# ...._ -AE-A URINAL ( - -I t WASHING MACHINE CONNECTION WATER HEATER ALL TYPES # �I - . .__-_f - -I --- -: WATER PIPING OTHER I '77i INSURANCE COVERAGE: _a I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESNO 0 IF YOU CHECKED YES,PLEASE INDICAT7THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICOTHERTYPE OF INDEMNITY0 I BOND 01 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: OWNER a AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicaWCOMPE, ate to the best of my wledge and that all plumbing work and installations performed under the permit issued for this application will ll Pe ' t the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLU;-7�jp AME Gp! ' • F LICENSE# a? GNAT MP EJ CORPORATION D# PARTNERSHIP DIV LLC Ek COMPANY NAME �Z /L- �' d� ESS - CITY /�JZyh ._ STATE I ZIP Ql TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �� Ll r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UT. 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address:_ City/State/Zip: ?n/'`liyJ r �� Phone#: 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. ❑New construction loyees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 1311 Other `Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. .ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site reformation. nsurance Company Name: 'olicy#or Self-ins.Lic.#: Expiration Date: ob Site Address: City/State/Zip: attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ,'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pain red penalties of perjury that rmation provided above is,true an correct i ature: Date: �! hone#: F0fJ,-calseiuonly. Do not write in this area,to be completed by city or town official, ity 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 Contact Person: Phone#: 1 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 of hire, express or implied,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 not more 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 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 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-contractor(s)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 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 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. Anew 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. #617-7274900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia Date..... .............. ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 41 ACHU This certifies that ........................................ has permission to perform .....c;2 ......................... ............................................... wiring in the building of.. ........................................ at... ............ .>1erth Andover,Mass. Fee.. Lic.No... . .. .ii Check # 70 i� Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. Wsy Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All`,work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notic f his or in ntion to perform th ectrical work described below. Location(Street&Number) e Owner or Tenant j Telephone No. 7 Owner's Address 10 5 Is this permit in conjuncXion with p building permit, Yes � ❑ (Check Appropriate Box) Purpose of Building ��/r1 C 'rit / � UtilityAuthorization No. Existing Service o?dE) Amps //D/QD_0Volts Overhead ❑ Undgrd 0 No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters s Number of Feeders and Ampacity ,n Location and Nature of Proposed Electrical Work: �� 00 Al 2,7 c/ Completion of the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices 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 WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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 9 BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and p�e ies o per ry, at h siorma 'on on d ' appl' ion is true and complete. 1 FIRM NAME: , r7 11C.-I /G LIC.NO.: fes/ Licensee: SIrkj.e—, Signature LIC.NO.: (Ifapplicable,e,ter "exempt" )the license numb e line. �p Bus.Tel.No.: Address: /YJL Y rc_ / oG/ JZJ Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of blic 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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ r✓✓ J �� w � � ��,��, � l� g— � �z/ 1 v D� � �i �a JS�� G �- ��Z � ��, f�� . � � �