Loading...
HomeMy WebLinkAboutMiscellaneous - 81 HITCHING POST ROAD 4/30/2018Date ..... -� Ilk 7 N2 J ........ /� ...... r. .. .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING *es that ......... 4. 1-7, �� a // C 93 This certifies ................. . ................................................................ 19 has permission to perform ......... ....... ...................... 8' CC ...... ..... ... . wiring in the building of ..... .................. ................................... at ....... .... / .......... rth Andover, M41 Fee ... .... Lic. No.... ................,r I INSA&R—, ..�2 -7 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 01hr Crnmmnnwettllh of 4Htt55arhu5rff5 :. Erpirtmrnt of rublir Msnfrig BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 Office Use Only Permit No. Occupancy & Pee Checked 3/90 (leave blank) 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 INK OR TYE -L INFORMATION) Date $-- l,f " � City or Town of�%y'�-�E� �r,- To the Inspector of Wires: The udersigned applies for a permit to periform the electrical work scribed below. Location (Street & Number) Owner or Tenant /I .s �L �1 11j i Owner's Address %t c_. Is this permit in conjunction with a building permit: Yes LT --No ❑ (Check Appropriate Box) Purpose of Building_!4 � Utility Authorization No. Existing Service fir' Amps -J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work l./. "''L Tye �vo `z;2 _-1 No. of Lighting Outlets I No. of Hot TubsI No. of Transformers Total KVA No. of Lighting Fixtures / Z ( Swimming Pool Above grnd. ❑ in- grnd. ❑ I Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets If-- I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Municipal Local ED "Connection ❑Other No. of Ranges ( No. of Air Cond. Total tons No. of Disposals I No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers HeatingDevices KW No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws have a current Liability Insurance Policy including Completed�OPerat ons Coverage or its substantial equivalent. YES `moi have submitted valid proof of same to the Office. YES �'�--7J� [ If you have checked YES, please indicate the type of coverage by checkine the ap�prop�rtaa -box. INSURANCE L�HOND G OTHER O (Please Specify) ! — _41 Estimated Value of Electrical Work S (Expiration Date) Work to Start _J-�y"-yi� Inspection Date Requested: Rough _ / v 9 s � ^ /� Final Signed under the Penalties of perjury: FIRM NAME I"' tr ,/ L LIC. NO. Licensee U t Signature LIC. NO. �/ Bus. Tel. No.,_Y Address �/t tno Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that The Licensee de the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) C'lJ (Signature of Owner or h.cer.t) Telephone No. PERMIT FEE S X-6565 Date. l/.:. . ........... TOWN OF NORTH ANDOVER Poo t PERMIT FOR GAS INSTALLATION This certifies that .... .............. has permission for gas installation r......... . in the buildings of .... I .......................... at ... North Andover, Mass. Fee —.?.v'..— Lic. GAS INSPECTOR Check# '�' 7 ) 6 AF MASSACHUSETTS UNIFORM APPLICATION AR PERMIT TO DO GASFITTING (Print or Type) /� %,'K/"ass. Date I Q f 7 Permit* Building Location 1kf61W-.-P067J, Owner's Name Type of Occupancy New Renovation p Replacement p Pians Submitted: Yesp No p G Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET ® Corporation 103C MIDDLETON , MA 01949 p Partnership Business Telephone 978-774-2760 p Firm/Co. Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No O If you have checked ,yes. please indicate the type coverage by checking the appropriate box. A liability Insurance policy KK Other type of Indemnity ❑ Bond O 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's Agent OwnerO Agent p i hereby certify that aft of the details and information I have submitted (or entered) In above appiption are true and accurate to a best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this' apptf n 1 in pl with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the r laws/ / 8y T of License: Plumber Signature of LiCOrgod Plumber or Gas Fitter Title Casftiter 3785 aster License Number city/Town Journeyman Y ONE OEM MENNIONE ENNEEMENEEMENER Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET ® Corporation 103C MIDDLETON , MA 01949 p Partnership Business Telephone 978-774-2760 p Firm/Co. Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No O If you have checked ,yes. please indicate the type coverage by checking the appropriate box. A liability Insurance policy KK Other type of Indemnity ❑ Bond O 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's Agent OwnerO Agent p i hereby certify that aft of the details and information I have submitted (or entered) In above appiption are true and accurate to a best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this' apptf n 1 in pl with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the r laws/ / 8y T of License: Plumber Signature of LiCOrgod Plumber or Gas Fitter Title Casftiter 3785 aster License Number city/Town Journeyman Location No. ,3 Date 2 ,.ORT1y TOWN OF NORTH ANDOVER ,, p Certificate of Occupancy $ . • Building/Frame Permit Fee $_ Foundation Permit Fee $ s�CHust Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 0�''�' 1�0;� f, 489.09 RAID 739 Div. Public Works {`�I'�`:N��.::z-" I Location 44cii I PC Q�, G No. C Date RSF 7896 Lct lo 1 1,3% 1.4 S TOWN ,OF NORTH ANDOVER Certificate of Occupancy $ .-- Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ r 1 Water Connection Fee $ _ TOTAL $ 1ST ti Building Inspector ,P� Div. Public Works Location ' 3 Ar �a No. OM Date 0 NORTiy TOWN OF NORTH ANDOVER pf tt�ao ,a �'b0 O? •' a OR „ Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ F �Sa�cHUSEt Other Permit Fee $ X.O Sew* connection Fee $ t � ! 9 /b Water Connection Fee $ 1D 77,50 TOTAL 199 � $ Building nspector Div. P li orks PERMIT NO. _034— APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP d40. •7 8. a� I LOT NO. Amada/ 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE ZONE SUB DIV. LOT NO. fv — LOCATIO� �� r� may, PURPOSE OF BUILDING tel) .r4 /j>C- / by 64 OWNER'S NAME /� d /yG�, , „_ / NO. OF STORIES `. SIZE -L'► CJ OWNER'S ADDRESS 'C' BASEMENT OR SLAB ARCHITECT'S NAME �y. I7 /` SIZE OF FLOOR TIMBERS IST _� _ 211D A, 3RD BUILDER'S NAME CSO,) SPAN DIMENSIONS OF SILLS y POSTS DISTANCE TO NEAREST BUILDING /"� DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES REAR "" GIRDERS AREA OF LOT 1 /9aIS, FRONTAGE / ' HEIGHT OF FOUNDATION p, /A THICKNESS IS BUILDING NEW pie S SIZE OF FOOTING X -LU IS BUILDING ADDITION t— MATERIAL OF CHIMNEYM7 I 4 IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND J t.© J WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER �i/ BOARD OF APPEALS ACTION. IF ANY �— IS BUILDING CONNECTED TO TOWN SEWER 1/ zs IS BUILDING CONNECTED TO NATURAL GAS LINE v leu INSTRUCTIONS a PROPERTY INFORMATION SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY EST REGULATED BY PARA. 114.H -S. B.C. _EST. BLLDG.DG. COST PAGE 1 FILL OUT SECTIONS I - 3 EST. BLDG. COSTPSR SQ. Pr - PAGE 2 FILL OUT SECTIONS 1 - 12 GJT�T ATO DATE 11,3113CFEEPAID ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR F E E iS 3� �- PERMIT FOR FRAMUBUILDING �o X PERMIT GRANTED 5a 10 t DATE: FEE PAID•. iqt� T s JAN 2 5 LESS MA FEL..- t DUE FIRM FUDR s- 145Q EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY NUILDING OWNER TEL. # 49 7s 3 34-5 CONTR. TEL. # 7 6— —3 3 CONTR. LIC. # G 0 17 �Lo 2- H.I.C. # `18�b -1 ie'ges BUILDING RECORD 1 OCCUPANCY 12 i SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI, FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 7 FnuNnennu I I a w,coins cw�cu L4 ON H ci m cooN \ _O .di O O Q c H D ,, : o z p ci es CD dd- e:m9cmn NA co O 0. Yfe i, Ic.i Mcm 1 C c m m a H O y t C S m y m c c y R O CO2 R Em o c act m y: c y Q •_ 8: mom V y O Z: Z O c Q coco y C C O m :mL3 * Hp d +-• p VD C ev = m M .y 'o.s CD oc 'E �•y O LU m omE:c g • elm _y a 00 :0 p� _ CO2M o y •� O � H t r0 O.�m -i �� �O 0 co OC � O 4-0 O v CL O C •� 0 M ,,I `•� W O o _ UM w E m •� m • O CL CD C O i > CM 0 CC.2 i D. �, tC O D. ca C p = Ca M C.) J 10 .0 Z CD O d U C.3 C O ev .0 y 0 Z 0 Q W cn Z O U J Q Z W Q W W cn a 0 � O o U w p w F+ A z y Q v u a w cn c ,.a y w z O 7 7 W 7 O Q w° C U w a°'%- C rx° w 04 V) ° G w V m cit ci m cooN \ _O .di O O Q c H D ,, : o z p ci es CD dd- e:m9cmn NA co O 0. Yfe i, Ic.i Mcm 1 C c m m a H O y t C S m y m c c y R O CO2 R Em o c act m y: c y Q •_ 8: mom V y O Z: Z O c Q coco y C C O m :mL3 * Hp d +-• p VD C ev = m M .y 'o.s CD oc 'E �•y O LU m omE:c g • elm _y a 00 :0 p� _ CO2M o y •� O � H t r0 O.�m -i �� �O 0 co OC � O 4-0 O v CL O C •� 0 M ,,I `•� W O o _ UM w E m •� m • O CL CD C O i > CM 0 CC.2 i D. �, tC O D. ca C p = Ca M C.) J 10 .0 Z CD O d U C.3 C O ev .0 y 0 Z 0 Q W cn Z O U J Q Z W Q W W cn FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Cao -s-'- I- or`,-/ etlK� Phone 1 , 33! -i LOCATION: Assessor's Map Number 3V- Parcel J Subdivision ti,:74 fz©sf- Lot (s) Street P05 r/c St. Number g% ************************Official Use Only************************ RECOMMENDATI NS OF TOWN ENTS: Conservation Admin'istrator Comments a/ vH"_ ()/ V .S it W1. Town Planner Comments Food Inspector -Health _A,A l �� Septic Inspector -Health Comments Date Approved /A0,11-1 Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date ApprovedzzL 119,J_ Date Rejected Public Works - sewer/water connections t - L3 -4s - driveway permit �// lJ II 13 -95 `5 Fire Department /�;Ct•�r�, �I�u4Z2t�Gu,���i 6fl/'!/ 6✓��9�r� Received by Building Inspector JAN 2 6 .r• Date vJF C•B.A.) 2q'1,6'3 W ' 241611 E .00' :. 67.58' 7 /ti Oka O -, OZ L=2,9 8 27.401 30.00 L = 27.40' R 30.00 :.3000' R = 60 00 rte41 . t ' 92.60' 15Q � ;4 GF F ` N O, O NLO _ 43' 560 S. F. 'O\ 2 09. 44 S. F 2� 22.gg D-H.(sef) 24 26, .H. (set) N E.NSF W 4 2.53 a P�r. Cor'►pany N 4 RC s OD WRAlIvsEF OF FACE . R� N 61° 18' 10 LOOT 9 43,560 S.F (- 140°0 D.H. D. H. (fnd.; n N 3SF34 29„ f )no wi CERTIFIED PLOT PLAN F LOCATED IN NO. ANDOVER, MASS. SCALE:1 "= 60' DATE:2/3/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. 30.00 \L= 27.40 R=30.00 �"90AO L=92.60 R=60.00 .-A . LOT 11 LOT 10 44,525 S.F. 30.5'+/_ co IT co to N LOT 9 Q S I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USEtY Of THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING o,� 72 H BY LAWS OF CONFORMITY OR NON -CONFORMITY v/StER�� NO. ANDOVER �'At callo s WHEN BUILT WHEN CONSTRUCTED. Z13 17S Location 1yl ►Jtz, �[�T No. e c- o cl c Date akir Ci NORTH TOWN OF NORTH ANDOVER pp� ' p Certificate of Occupancy $ • ; ; Building/Frame Permit Fee $ Foundation Permit Fee $ 1ACMU5 —?Other Permit Fe&Aj1�1 $ `S1J N Gam- Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Of7q Building Inspector - T, U Div. Public Works . g�5s KAREN H.P. NELSONTown of 120 Maih Street, 01845 Director ' (508) 682-6483 o � T BUILDING °,' �•.'�9 NORTH ANDOVER CONSERVATION ss " '` DIVISION OF HEALTH PLANNINGPLANNING & COMMUNITY DEVELOPMENT DATE LOCATION w OWNER'S NAME BUILDER'S NAME MASON'S NAME CHIMNEY APPLICATION AND PERMIT r MASON'S ADDRESS ..�0� �ir•/YT/i�/�'� MASON'S TELEPHONE � r MATERIAL OF CHIMNEY 0),�q t�- PERMIT #,a�-,Pag c, INTERIOR CHIMNEY , EXTERIOR CHIMNEY Cr NUMBER AND SIZE OF FLUES THICKNESS OF HEARTH .-e4Q Will chimney or fireplace conform to requirements of the code and have rules and regulations been received:,,/ DATE SIGNATURE OF MASON CONTR. LIC. EST. CONSTRUCTION COST/CONTRACT PRICE PERMIT GRANTED \� E ROBERT NICETTA, BUILDING INSPECTOR INSPECTED 4 REMARKS 11 SOLID BRICK REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES d^�J W M O O CL z V o � w a :a Ui J . Q M O \L.d Cl V Z d W LLJ Lig. i1m C6 a IA I V J s-- co CD E r �� co L ~ O � LLJ Z O V! z z 0 O Of w o 'O > Q O CO) Co .� � W ' Cc co z 0 oc i a Q U im con O L i \` ° ti cn o ° ii o o cn ao' w' cn cn W M O O CL z V o � w a :a Ui J . Q M O \L.d Cl V Z d W LLJ Lig. i1m C6 a IA I V J s-- co CD E r �� co L ~ O � LLJ Z O V! z z 0 O Of w o 'O > Q O CO) Co .� � W ' Cc co z 0 oc i a U im O O i Cc a C CMCX ca O 'C O O O Q Z LL C cm O Z V O y O r n ` v cc W CL N3 G3 Z z � � ' z W w CL Cj) F W - 100, a- L H '.,49 :v.a-:.s- Location No. j Date 4/l/c/ NORTry TOWN OF NORTH ANDOVER O�O•,t`•O ••,hO R Certificate of Occupancy $ •a Building/Frame Permit Fee $ Foundation Permit Fee $ �— JACNUs E Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 04/2o/99 14:29 143.00 PAID Div. Public Works L) J M I VII Z L 1 )i o, 4 N N az ri ►.. ;t C N i N z 1 CJ �i z � u V) r4 .J.I — X ^0 C Q 1J N L J N J Z a C LLI J � o, J 6 `J w � Z Z � -K r -3c F ►r , C W n J H Y H y+ w W C _ Z Z y 5 ._ _ rd V L:, Q Q U Z Q n zAt n E9 � Ln W Z Z L` F (If � N F- � z z Y C < Z L:jZ Z y Z Ci z z — N �. Z w r W w = _ z ¢ 'n 4 ¢ •n < .V m _» VII f Z L 1 )i o, 4 az i N y L Z �i z � u .J.I Q Q 1J N L J N J Z a C LLI J � 6 `J w � Z f ,,_ r A L 1 )i o, 4 az y L Z �i z Q U ,,_ r A `oo ro o �a> GLL n n Cl) O Z U) D O U w _I _ m _J � a W L >O N } Z ._ , Z m Z w O Q 6,9 L 6,5 L epi (-I I L. LLXL JI, LL,£Z '1 Z,Z c a b Q 1, U � "¢ A � v u S2 o w° v u cn o z Q a ° C-0 w° a v U �+ w � `� r' c�° m w � W _� U U W X00 P4 � w x o � z � U ion m w z w x � w Ca a w v CO d z cn o u o LLJ 2 N fel C/! CDy .CD L co C O Cu C.1) CD M CO2 0 C� N! C O Co cc Com. CA 1;11� 7 L 0 ..r C.3 Cly CA C Cid 07 C CD O C m m 0 CD H i 3 .a D O 0 0 O CZ CZ cma C � C cc 0 CO Z Q COD C w U) LLJ U) w LU crw LU (1) � CD c N W :cam o �_.,� - IL c O N r.+ C •c�.� ) d= Fy .m cc v' a cc CD m o O CD � C O V� m ' 42 N O oco co _ � M: C CD m g �. � �. z a N E m O V O u tm m C E N N m m m d O N LO2 Cf) m cm m N •03 .0 C C fT` N O O FF ii JJ E m H m cm ID CM A aCDCOQ c .oma ev ' � oc N fel C/! CDy .CD L co C O Cu C.1) CD M CO2 0 C� N! C O Co cc Com. CA 1;11� 7 L 0 ..r C.3 Cly CA C Cid 07 C CD O C m m 0 CD H i 3 .a D O 0 0 O CZ CZ cma C � C cc 0 CO Z Q COD C w U) LLJ U) w LU crw LU (1) � N W C �_.,� - IL Fy .m m •N CD d O CD � C O V� m ' 42 N _ � N fel C/! CDy .CD L co C O Cu C.1) CD M CO2 0 C� N! C O Co cc Com. CA 1;11� 7 L 0 ..r C.3 Cly CA C Cid 07 C CD O C m m 0 CD H i 3 .a D O 0 0 O CZ CZ cma C � C cc 0 CO Z Q COD C w U) LLJ U) w LU crw LU (1) � Date ..... 492 + TOWN OF NORTH ANDOVER 0 MONOW W PERMIT FOR WIRING CHUS This certifies that ...... ....... has permission to perform ................ wiring in the building of ....... . . ...... ................................. at .... 47�� xv�'e .. ..... .... . .......................... . North Andover, Mass. Fee... ................ 10/02/96 6:02 35-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer office Use Only uhE (ZfUM 1111 halt I IIf 5k.�5ziL4uuiPtts Permit No. T ~!� ErpartulziTt irf iluhiir fEttj Occupancy &Fee Cnecked � (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 9.27 VJR 12:00 S APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Q�� or Town of NORTH ANDOVER To the Inspe for of Wires: The udersigned applies for a permit �tOqer-f�ormtlhe�eiec gork described below. Location (Street & Numt1erJ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Purocse of Suildinc Existing Service Amps _J Vci•ts New Service Amps /—Volts Numcer of Feeders anc Ampaclty Lccaticr, anc Nature of ?rcpesed =_:ectncai 1,11crx No. or L:gnung Outlets No. of Lighting Fixtures Yes No I_ (Check Appropriate Sox) Utility Authorization No. Overread Unogrnd No. of Meters Overread _ Uncgmc No. of Meters No. ct pct �os Abcver— in - Swimming Pool erne Total No. of 7ranstormers KVA IGenerators KVA i I No. of Emergency Lignttng � Nn. ^_f Race^tacie Outlets No. of Cil =urners I Saaery Units , No. at Swncn Outlets No. or Gas _urr,ers oral No. of Ranges I No. of Air Ccr.c. tens Heat Tatal Torar No. of Disposals No•ct Purr.as Tons Kw No. of Cisnwasners - i SoacetArea Hearing No. of Criers j Heartnc Devices KN NO. at No. at ^r '_vJ f-loarcrs KVJ i Signs Ballasts Nn -4"" nnaasane Tubs I No. of Mcicrs Total �'P OTHEP.. FIRE ALARMS No. of Zones No. at Detection and initiating Devices No. of Sauncing Devices No. of Serf Containee Oetec,;oniSounaing -Devices Local Munic:oai Other _ Connec:;on — Law voltage Winne INSURANCE CCVERAGE. Pursuant to the recuirements at Massacr.usecs general Laws I have a current Liaotiity Insurance Policy inclucing^,�m^let c Oceraucns Coverage or ;ts suostanual eewvaienc. YES NO nave suamiGee valid proof et same to the OHics. YES ,PND _ It you nave cnecxecl YES. please ineicate the ryee/iat coverage cy chec:(ing the aoproC ate cox. (/ INSURANCE �CNO _ OTHER _ tP:ease Scec:!y) ( xairanon Oatei Estimatea Value of Ei.ectncal work 5 �DOO Wcrx :o Start Insoecaon Date RaCLes-zec: Rougn Final Signed unser the Penalties of perjury UC. NO. FIRM NAME _-- IC. NO. — Ucensea Signal 7 ^ �9 C r �e ��,�� �e4e4 r A) A� 03a3�_3as. ,,,,yd. Address C AIt. Tel. No. OWNERS INSURANCE VVAIVER: t am aware that the Licensee does not nave the insurance coverage or its suent, ow eautvalenAt as re- OWNER'S ov Massachusetts General Laws. and that my signature an ^.is cermt application varves ;his reauiremeni. Owner g (P!ease cnecK one) –etecncne No. PERMIT F_= (Signature at Cwner V agent)