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HomeMy WebLinkAboutMiscellaneous - 85 BOSTON STREET 4/30/2018 (2)I MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108.1904 (617) 723-3800 Ma Only (800) 392-6108, FAX (8001851.8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch.139, Sec.313 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: XIAWA WANG AND ZHEN LI Property Address: 85 BOSTON ST, NORTH ANDOVER, MA 01845 Policy Number: 1280932 Type Loss: Ice Dams Date of Loss: 0310912015 Claim Number: 335593 Claim has been made involving loss, damage or destruction of the above captioned property, 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 36 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 312412015 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617)723-3800 Ma Only (800) 392-6108. FAX (800)851-8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: XIAWA WANG AND ZHEN LI Property Address: 85 BOSTON ST, NORTH ANDOVER, MA 01845 Policy Number: 1280932 Type Loss: Water Damage: All Other Water Damage Date of Loss: 06/1212014 Claim Number: 323857 Claim has been made involving loss, damage or destruction of the above captioned propert, 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 the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 612112014 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723.3800 Ma Only (800) 392-6108, FAX (800) 851.8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Address: Policy Number: Type Loss: Date of Loss: Claim Number: CMA00021 XIAWA WANG AND ZHEN LI 85 BOSTON ST, NORTH ANDOVER, MA 01845 1280932 Water Damage: Plumbing Systems 02/10/2014 320601 Claim has been made involving loss, damage or destruction of the above captioned propert, 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 the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division 2/12/2014 This certifies that -,z . .e =.� has permission to perform ..... /OP --70 , .......... . wiring in the building of ... e ,,,,,,,,,,,,,,,,,,,,,,, at .. ,,.. �. �OS k� . , N h Andover, Mass. Fee. I ....... Lic. No. X147?... !!io/ .... z ELECTRICAL INSPECTOR / Check # 11 132 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services —� 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 C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: AA City or Town of: NORTH ANDOVER 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) OF,5 �a Owner or Tenant Owner's Address Telephone No. ,3-b f-- .TS -7, 2 % i'Si Is this permit in conjunction with a building permit? Yes ❑ No 'Q' (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Insnector 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 K -VA No. of Luminaires Swimming Pool Above ❑In- 1:1o. nd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g 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 El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW 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: ` 0 — ti �j �I t. n pump S `1 s—Fe f .l Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elec ical Work: /rbo, o (When required by municipal policy.) Work to Start: 0 j ,-JL- 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 c ver ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (BOND ❑ OTHER ❑ (Specify:) I certify, under toe pains and penalties ofper that the information on this application is true and complet r FIRM NAME: GTA -y 4. I tv % t L.0 -071`4-G A -L- "- t..L LIC. NO.: Z q Licensee:,7�+�� j�-gtvN-T L"Ld Signature LIC. NO.: :� 44si7 c (If applicable, enter `exe t" inYhe license nuaber line.) I� / V d y Bus. Tel. No. % 2 Address: PiGs T- !1 t�/� M U fN M Alt. Tel. No.: q&ZI j t' *Per M.G.L c. 147, s. 57-61, security work requires Department of Public 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 a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. }�The CommanweafthqfMassuckweft 1 rt a I r r r r ulp ,� / I • JI /► I I ►�I r IBo&oj7, AIA 021 U w • r .r , Workers' Compensation Ir:nsurance.Afdavit: Builders/Contractors/Ir+Iectx-lciansMIumberq AUplicautWorm ation Please Print Legibly Name (Business!Organization/Individual):TA'TP.` f WE Address_..- 110 AC k%ons ST leAll. City/State/Zip: M S"ft EM $ M A a DI Vyy Phone 4:_q_` 9 13 q,� Are you An employer? Check the appropriate box: 1.1 am a employar with_„ 4. 0 I am a gmeaal contractor and I . Type of Project (required): __ employees (fall.and/orpari time).' have hiredthe sub-confraciers 6 I] New construction 2. [. j ram a sole proprietor arpartuar .listed on fhe attached sheet 7. F] Remodeling snip and have no employees Mesa sub -contractors have 8. [] Demolition working for me in any opacify. [No worms' comp. insurance workers' comp. insimme e. $' 01 We am a and its 9. ❑ Building addition . eqt regnired,� officers have mmoiis sed f m 10. Slecttical repairs or additio.-S 3.0. l am ahomeownet doing all work riAt of enmption per MOL 1111 Phumbiugrepahs or additions myself (Nowo&MW comp. c. 152, §I(4), and weban no 12.[1Roo£xepais iinsttraucexeel}xiredj f employees. [No workers' 13.Q Other exp. insurance,remhrAI r�+yu�aurmarcnemnoxelmasreuroratowmesectionbwcwsnowingtmfrwodBm' swonpougyb�miaecuL FI sia wbo submit VAs df$davftbAQfttf ngdmY ere doing sit work andihmbim unbMs cans is nmstsnbmSanm affidwkkdkaiing saab. �t3ou ;C"z sthatoheatcthisbummtetiaatudenadftonWabwtAbDwkgih*z= eofthesub-0onft=ftsaadtheiry/ad ecamp poli7mftrmston Inman wWloyerthatisproWftgvorkerslcompensafien insurance foTnV employees Befow is ihepoficy andjob site in, for�aation. Iusi>zance Company Name. C7 Policy # or self-ims. Lic. #: V 8' W EC " 04 3 4 y $xpiration Date: rob Site Ad$=_ VU" Cify/S`taGe/ i:IVA\-;�uvacmk Attach a copy of the workers' compensation policy declaration page (showing the policy nwnber and expiration date). Failure to secure coverage as rerquiredunder section 25A of MILL e. 152 can leadto the imposition of crinainaipen.N. ofa FMO up to $1.500.00 and/or one-year imprisomnent, as wall as civil penalties in the form of a STOP WORK ORDER and a fine ofup to USO -00 a day ag &tithe violator. Be advised $tat a copy ofihis statement may be forwarded to the Office of hrestiFdons oft ieDIAfQrffi2surmce coverageveaification. Ido hereby-cenV dw informatlonprovided aboveistale and correct Offiefal rase osiij►. Do PtoV verde in this area to be completedby city or town of dal Uty or Town: Perm1tUcense# IssWngAtcthority(drele one): X. Board of $ern 7,33URdnng Department 3. City/Town Clerk 4. Electrical hVector 5 PIumbing Inspector 6. Other CautactPerson: PTtona #: 11 I Location No. -/ Date t� -4 to,- ._ TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ ^' E S Building/Frame Permit Fee $ AC MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ `> e Check # /-53 17L, o Building Inspector 1.1 Property Address: Y'S 6oS7-0tj Sime 1.2 Assessors Map and Parcel Number: 0� -/o/ Map Number Parcel Number �/D�Tr/ �9.al,�ovE�z ko,dPrf ,� P,//Y, Name (Print) Address for Service 6 1.3 Zoning Information: Zonis Distrid Proposed Use Signature Aeleph6he 1.4 Property Dimensions: I Lot Areas Frontage ft 1.6 BUILDING SETBACKS M Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 3.1 Licensed Construction Supervisor: 1.7 Water Supply M.G.L.C.40. 54) 1.5. Public ❑ Private ❑ Zone Flood Zone Information: Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ko,dPrf ,� P,//Y, Name (Print) Address for Service 6 Signature Aeleph6he 2.2 Owner of Record: a Name Print Address for Service: s Si na re Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 P egisteredd Home Improvement Contractor Not Applicable ❑ �( / c� / Company Nam m � r r/ -14 ?ro Registration Number Address — Expiration Date Si na re Tele hone MU M X z 0 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check altapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ 7terati ons(s) , Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: G44x' `�y 4 .PXs►s�r �t�g G � . SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OMCIALVSE ONLY ',' ­'.1'1:;' I. Building C� !� (a) Building Permit Fee Multi lier 2 Electrical / • ©C3 (b) Estimated Total Cost of Construction 3 Plumbin. D Building Permit fee (a) X (b) •J v 4 Mechanical (HVAC) 5 Fire Protection EkSiS?-�� 6 Total 1+2+3+4+5 G Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT CONTRACTOR APPLIES FOR BUILDING PERMIT /O1R 1, ;N110141/ , as Owner/Authorized Agent of subject property Hereby authorize �Gf /1�01' Q P � � 0— ( -(L. to act on My be all att r relative to work authorized by this building permit application. (Z- 1 F- 6--s Si re of Owner Date SECTION 7b,�OWNER/AUTHORIZE/D AGENT DECLARATION I, '//// ' (c? S C / {� 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 Own er/A ent Date N OF STORIES SIZE �ASEMEn2R SLAB S OOR TRVIBERS 1 ST2ND 3RD SPAN DHAENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION (j '' THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS: This form is used to verify that all necessary approvals/permits f Boards and Departments having jurisdiction have been obtained. This does n rom the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION APPLICANT �i c u.f� v / 1•LC . ��,.r�z PHONE { LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET 17<) ST. NUMBER - RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APP ROVED DATE REJECTED COMMENTS s} TOWN COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH DATE.APPROVED DATE REJEcTr-n DATE APPROVED DATE REJECTED DATE APPROVED d DATE- REJECTED n► PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: ��• ��" Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one worldng in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address C(��c Insurance: Co. �G (��c:,�-�v-� c �c`�' 4' PofiCV# � Comoany name: �G!E ("�2 >� ,iGc� 5 l r/► � C�c �( L Address .. 11111ei (1i7 S ✓� `t` %r. /I�G�f'""�i L� ? G'i/`P Ptortg'#k Insurance Co. Policv # " Faikwe to secure coverage as required under Section 25A or W- tL 152 can leadtathe Irnpostiiar 4-*c*r*WperwWwwcr. afirm up -to si'm and/or one years' imprisorrnentas welL= faSTDP foe -a -O=M ajlagF me understand that a copy of this statement may be fonwarded to the Ofte of 1nvestijadom of the DIA for coverage ver cation. I do hereby certly under! the pa'ks'and penetties of pe6my OW the k&inieftn provided above is true and correct Signature'%� 'L -c _ (�'l� Bate 4? Print name �� OffidW use only do not write in this area to be completed by city or town dficWr city 0rt1 Town 8191*ng Dept []Check d kwmmobte response is reguked Lker n(o Boal Se%8marf's o Contact person: Phone # F-1 Health Depart! E] Other Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR a Registration: 140534 Expiration: 10/23/2005 Type: Individual CASALE CONSULTING MICHAEL CASALE 8 STAFFORD COURT HAVERHILL, MA 01835 Administrator dN' .9Z I ks £.5 � 0 hb � -(> -(> -�y n L W I N -a: U in N E ~ Z o �� 3 p ca fLS N T U C O LL ap p U N c000 O L N N U Q i N = C W - CD p N E CD C:-- N p C 6m - 0 w in u 04 cu ACORD CERTIFICATE OF LIABILITY INSURANCE 7DATE(MM/DDIYYYY) �+ 12/22/2003 PRODUCER MACDONALD & PANGIO.NE INSURANCE 104 MAIN ST NORTH ANDOVER MA 01845 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED MICHAEL CASALE DBA CASALE CONSULTING 8 STAFFORD COURT BRADFORD MA 01835 INSURER A: PREFERRED MUTUAL INSURER B: INSURER C: INSURER D: INSURER E: CAVFRAnFA THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADDT INSRE TYPE OF INSURANCEDATE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION (MMlDDlYYl LIMITS A GENERAL LIABILITY TBD 12/22/03 12/22/04 EACH OCCURRFENNCE $ 500,000 PREMISES Ea occurence $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE © OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ 1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1 000 000 LlPOLICY E 0 LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR EICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS W 0-S -R�o S4- I 'JS -4.-- Alt CQ_ �� 4 � f`FRTICIrATF HAI nFR CANCELLATION ACORD 25 (2001/08) UACORU GORPORAIIVN 79S5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF NORTH ANDOVER BUILDING INSPECTOR DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL I NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 120 MAIN ST NORTH ANDOVER MA 01845 v REPRESENTA es. AUTHORIZED RE TIVE ACORD 25 (2001/08) UACORU GORPORAIIVN 79S5 et zr 0 z rA W (z O A o v u o w° U)v CL cn Cd U z U q z o G V° :J C2 U co�''' w 94 O W U m d cdW w R. w U w 1 cn w x p a z a ' m w z d % a w a� o z vi Q o cn goil _' v .TIT v a .i+ 2 V O O � v Z O y � c W cm O 2 O O E C13 m C3 03 � H L C Z., t+ �j •a as O c e_cv o a CL C o c O O CA C.3 C G3 C.3 h c C cc d COD Y/ Y/ W W 19 W W C � m C • C r O = r O C3 V CL C to R ymC ? vrr OL � Ea at vl Q or4 om CD U �O„ V = c ' m C • a:. L m m a y m r y A = � CLC.) A.: m m Om cc 1 r .... CCl V HZ O g. a m e m C C mr o = ~ m N Vi Ltd r o y mr~ L' tip Z m r 4 •ffA ._,,,, CD W C H ac LAJ �E aL Z cma y o 45 !9 _ = CI a= m 9 goil _' v .TIT v a .i+ 2 V O O � v Z O y � c W cm O 2 O O E C13 m C3 03 � H L C Z., t+ �j •a as O c e_cv o a CL C o c O O CA C.3 C G3 C.3 h c C cc d COD Y/ Y/ W W 19 W W Date...../ .../� ..0( TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform .. s `� wiring in the building of dh e� � 4 ,.. .................................................. .............. >- t 6CJ5 fdv�.....s%.....................North over, ass. at ................... ....... Fee.............. ..... Lic. No.............. ...............................: �....... ELECTRICAL INSPECTOR Check #_ 4 49 Commonwealth of Massachusetts Official Use Only I Permit no. Department of Fire Services Occupancy and Fee Checked - BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR, TO PERFORM ELECTRICAL WORK All work to be performed i .accor`dance with the Massachusetts Electrical Code (MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1.7.2004 City or Town of. North Andover! To the Inect re o{{Dire By this application the undersigned gives notice of his or her intention to perform electric LIP, - de criObi elow. Location (Street & Number) 85 Boston St Owner or Tenant Robert Owner's Address 85 Boston St Marie North MA 01845 Is this permit in conjunction with a building permit? Purpose of Building residence Telephone No. 91 - Yes ❑ No [X] (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Overhead Undgrd [-� No of Meters New Service Amps / Overhead Undgrd F� No of Meters Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work: inst. 11 rec. lts.;I plug for iron; 15 out. on 2 cts.; 3 sets of 3 ways;2sw. & 2 Its. in laun.rm & boiler rm.;sw & It. by back door No. of Recessed Fixtures I I No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures 3 Swimming Pool Above In- ❑ ❑ No. of Emergency Lighting rnd. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones 16 No. of Switches 5 o. o as Burners No. of Detection and Initiating Devices No. of Ranges No of Air Cond. 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 HeatingKWoca Municipal Other ❑ Connection ❑ + o. o ryers Heating Applicances KW Security Systems: No. of Devices or Equivalent No. of Water Kit No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices of Equivalent No. of Hydromassage Bathtubs No of Motors Telecommunications Wirin : Total HP No. of Devices of Equivalent_ OTHER: INSURANCE COVERAGE: Unless waived by the owner, no permit faro iie perro°rnmance i�lde�ect�r1 a� wc�1' rma� lssueptin�'edtliie S' 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 F] BOND[—] OTHER 13Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1.6.2004 Inspections to be requested in accordance with MEC Rule 10, and upon completion I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME Power Wiring & Emergency Response, Inc. LIC. NO.: A17354 Licensee: Stephen Decker Signature 1149.-..._ LIC. NO.: I-800-418-3221 (If applicable enter "exempt" in the license number line) Bus. Tel. No.: Address: 44 Stedman St, Unit 2, Lowell, MA 01851 Alt. Tel. 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) DwnerDwner's agent. Owner/Agent 75.00