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HomeMy WebLinkAboutMiscellaneous - 8 LACONIA CIRCLE 4/30/20184 N 2 Date............./......... N°RTH 1 °ft�``°;•'"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..........,J�.... v F < r, ' / f � - ...................:...................................................... has permission to perform L , % `i .............y,............................................................. �J wiring in the building of %? �. %� ilv" t 1 �qCd at............................................................................North Andover; Mass. Fe.. ...� ......... Lic. Na.�3�,'....�:':.r.., `................. !ELECTRICAONSPECTOR Check # �S / WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 9800 Fredericksburg Road San Antonio, Texas 78288 USAW 04664.14XPZ.JSS748604537.01.01.419 TOWN OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER,MA 01845-2420 6C? November 25, 2013 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Attention Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Frederick W Kulik Reference #: 000435900-5 Date of loss: November 24, 2013 Location of loss: North Andover, Massachusetts A claim has been made involving loss, damage or destruction of the property referenced above, which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 33490 SAN ANTONIO, TEXAS 78265 Fax: 800-531-8669 Phone: 25027 Sincerely, Michele A Rutkowski Northeast Region United Services Automobile Association P.O. Box 33490 San Antonio, TX 78265 Phone: 25027 Fax Phone: 800-531-8669 000435900 - DM -04664 - 5 - 6774 - 52 54577-0813 Page 1 of 1 Official Use Only Permit No. 3 IV& C0911%OXWEALOfOFW",40WSE`IrS Department of Pu6GcSafety Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 7/R 12:00(Please Print in ink or type all information) Date 1l © 0 To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. tt Location (Street & Number D Lprcatz to - CI, 9642 Owner or Tenant Owner's Address �� C Is this permit in conjunction with a building permit Yes 0 No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing ServiceAmps Voits Overhead p Undgmd 0 No. of Meters New Service Amps Volts Overhead p Undgmd 0 No. of Meters Numidbr of Feeders and Ampacity Location and Nature of Proposed Electrical Work INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES - NO = have submitted valid proof of same to the Office YES - NO - If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER - (Please Specify) (Expiration Date) Estimated Value ole trical ork$ Work to Start O / Inspection Date Resquested Rough Final Signed under the Penalties of perjury: LIC. NO. FIRM NAME j �{� Q Licensee V e ' • ' Signature Q LIC. N0. Bus. Tel No. 1 7 y `Q. _ �� Address e • C'' a MA Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA / ppe�Above In 0 No. ofhting Fixtures .5Swimming Pool grnd p 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 Rang.. No of Air Gond Tons Initiating Devices No. of Sounding Devices Nod of Self Contained No. of Di sal Heat Total Total No. Pumps Tons KW No. oDishwashers Space/Area Heating KW Detection/Sounding Devices p Municipal p Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hvdro Massage Tuds I No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES - NO = have submitted valid proof of same to the Office YES - NO - If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER - (Please Specify) (Expiration Date) Estimated Value ole trical ork$ Work to Start O / Inspection Date Resquested Rough Final Signed under the Penalties of perjury: LIC. NO. FIRM NAME j �{� Q Licensee V e ' • ' Signature Q LIC. N0. Bus. Tel No. 1 7 y `Q. _ �� Address e • C'' a MA Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent)