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HomeMy WebLinkAboutMiscellaneous - 863 WINTER STREET 4/30/20188 Date .6.-A..o-.1.(... JORT" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING rSACMUSE� certifies that ..G Z: vvk ....Q.i.V.1(M.{3.i.YK G ............... . permission to perform iC + � ............. bing in the buildings of ..G. 1AYLA .S..0.vfwl 0S. ......... . . . Loi .✓l kr . ...... , North.Andover, Mass. Lic. No.. �t �. t . .... ,f .(;� . ... ' .... PLUMBING INSPECTOR INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes Q No ❑ If you have checked Yes. please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 91 Other type of indemnity ❑ 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 Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent I hereby certtly that all of the details and Information 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: rtie ❑ Plumber Signature ofticennssed Plumber �ityRown ❑Master License Number: -1 O APPROVED OFFICE USE ONL []journeyman 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING CttyITowniz) 01*6% hv, k zu tk , MA. Date: Permit# Building Location: s' ro 3 vet 1 YIi9VC S Owners Name:Q ` T 1 s )ay i t s Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [] __== -New: ❑ `Alteration:,❑ Renovation: ❑ Replacement: ® Plans Submitted: Yes ❑ No INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes Q No ❑ If you have checked Yes. please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 91 Other type of indemnity ❑ 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 Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent I hereby certtly that all of the details and Information 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: rtie ❑ Plumber Signature ofticennssed Plumber �ityRown ❑Master License Number: -1 O APPROVED OFFICE USE ONL []journeyman 0 FIXTURES Z U) z O IX U) Z_ Y F Y} � uy Q V a N N rn O it N 3 W = 4' 9 Z d W ~ N W Z W Z N Q Z D X a .� .M .a N Q W a OF a W ra W J O Z U a 4 V O y N O O N V Z Q >.O 0 OJ r W W W W Q Q a _M to o a Q 0 H> c� s Y g g o: = rn rn Q I- Q 3 Q 3 Q O Sub BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR J -.-..FLOOR 5 FLOOR 6 FLOOR 7 -FLOOR -i'FLOOR installing Company Name.�rE. M ��u►tc.���ae,1`y�ce� h� Check One Only Certificate # e ® Corporation 2 Cc,c'1 '1 Address N\z,,) q.%\^r, �' r,:,o Q City/Town: �, % "t o, h State: ❑ Partnership Business Tei:'ka\ 63101 i`"1ccLd\ Fax: ❑ Firm/Company Name of Licensed Plumber:. '7'v► \-"C) 4xk^tom INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes Q No ❑ If you have checked Yes. please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 91 Other type of indemnity ❑ 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 Owner ❑ Agent ❑ Signature of Owner or Owner's Aaent I hereby certtly that all of the details and Information 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: rtie ❑ Plumber Signature ofticennssed Plumber �ityRown ❑Master License Number: -1 O APPROVED OFFICE USE ONL []journeyman 0 . rrn I T n� T. l EA t y Y a . rrn I T EA a .S. CA i . _ ..... _ ,... - 'a f ,ase i ;}+ i .� i� .�$ � 'e�' i C''^" �y9, J ✓�.. � - i. 7 .. _... Y .. 1 r" CA I r. Z �I ... . ..... ...._.. _.,...._._.e .. ....- _._..,__ .._..__.._4. -31 7706 Date ... ...... �0In TOWN OF NORTH ANDOVER -,t PERMIT FOR GAS INSTALLATION a o .4y This certifies that ....6. 4 ?n : � . (.4! 6A.eA Nev. . has permission for gas installation . L,.A-. V! C<1.. R fo kCP—... . in the buildings of ..... . S� 0.0.1.4') ............. at .. Ea. .. `. r) -.T..-?A ..... , North And ver, Mass. Fee.0°.. Lic. No... � .......... GAS INSPECTOR Check # r. 'h®Ast MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING CitjiTown:,�, �) iF`nn IMW' MA. Dater Permit* FIXTURES Building Location: UA r*,yr:Ei Cwners Name: I i T pe of Cccupancy: Ccr merciai ❑ Educat Cral ❑ Indus:mal ❑ irst:iuticral ❑ Res:dertial New: ❑ Alteration: ❑ Renovation: ❑ Replacement: V Plans Submitted: Yes ❑ No ❑ 'h®Ast �j y .d FIXTURES LU Lu� = 0 0 F- til vi Ul w uj ZO © Q (L Q c O Lu w X t= us v V Lu O Lu J Z w N i O E.. Lu Tin 2 d W � � > WZ. o o���. tom- F= i i�> O Z .1 0 O Z u. 0 �> z a= UJc0� SUB BSMT. BASEMENT k 14t FLOOR k 2' FLOOR I 3 FLOOR k 4 FLOOR 5` FLOOR k k k k k :,6 ::FLOOR 7 FLOOR k 8 FLOOR { InstaUing.Ccr .pang Name -Q7, E M "'It, R a. vsc Check Cne only Cefficate'r!' t ( Cor;,cration z 1 ❑ Partnership BusinessFax: ' ❑ FirniCcmpany Name of Licarsad Plurmber!Gas Fit'.9r77 C ' t. INSURANCE COVERAGE: I have a cur, ant liability Insurance pciic7 or Its substart`31 equivalent, A(hich meets tt;e requirements of MGL. Ch. 132 Yes No ❑ if you have checkad Yas, pieasa Indicate the t•/;.e of c;; rera,e by check:rg the appropriate box below. A Iiacilit j insurance policy Cher type of indernnitj ❑ Bond ❑ OWNER'S INSURANCE WA, /_R: i am aw a that the ticarsee does not have the insurance coverage reGuirad by Chapter 132 of ti•e Nassachusatt3 General Lv", and that my signs ure on this permit application waives this requirement Check One Only ❑ Slcratt:rs of Cwrer or Owners Acent Owner C3 Agent 3y checking this box ; I hereby cert.`ty that ail of the details and information I have submitted (or entered) regarding this appilcation are L%e and accurate to the hest of my Knowledge and that all plumbing work and installations pertcnned under the permit issued for this appiicaCon will be in compliance wN1 all PertUent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Plumber Title C] Gas Firer CS Master Signature of Licensed Piumber,RitterGas Cir town ❑Journeyman License Number. co Z—v APPRC4E0 ICF?ICE USF ONLY) ❑ LP Installer .ILA 1) I iZ li ti ro o Ell M Ell M ISOM. V e" Date .A .... -) .... 7 ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... 4/" ...... .......... ...... ................................ has permission to perform ..... ....... ...q . ......................... wiring in the building of......... .............................. ........................................ at ...A.3.... / -- -,G . ... .......... North Andover, Mass. Fee ............. Lic. No. //2I.V ........ ELECTRICAL Check # 750 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEY), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 0 7 City or Town of: NORTH ANDOVER To the Insp etor df, Wires: By this application the undersigned gives notice of his or her intentign to perform the electrical work described below. Location (Street & Number) $°(y l �.`�r— � i Owner or Tenant Ll &)4JC-�,v V-e—g Owner's Address Q Is this permit in conjunction with a building permit? Yes C Purpose of Building D Telephone No. 920P-6L1!C—%j� No (Check Appropriate Sox) 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: Cmm�tation ofthn in/ln...;nom Y. A/- . , h a t....i �.•:---- Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectrical Work: 300, °D (When required by municipal policy.) Work to Start: o? p Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: 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 of perjury, that the information on this application is true and complete. FIRM NAME: �-�Sl�ry LIC. NO.: Licensee: � Signature _ LIC. NO.: 1-9 ->t "JW (If applicable, enter "exempt - in the license number line.) Bus. Tel. No.: 97V372^c ;%��% Address: ®r2 erg 0& Alt. Tel. No.: ikZ-813'9879 *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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $--- (, ---- -----.. - �.... ....••.••,• .,..�........ — —, a "m ma ree ar v rrtry No. of Recessed Luminaires No. of Cell: 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. rrid. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond.Total Tons 5 No. of Alertin Devices g No. of Waste Disposers Heat Pum 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 Devic No. of Water No. of No. of s or Equivalent Heaters KW Signs Ballasts Data Wiring: 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 lectrical Work: 300, °D (When required by municipal policy.) Work to Start: o? p Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: 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 of perjury, that the information on this application is true and complete. FIRM NAME: �-�Sl�ry LIC. NO.: Licensee: � Signature _ LIC. NO.: 1-9 ->t "JW (If applicable, enter "exempt - in the license number line.) Bus. Tel. No.: 97V372^c ;%��% Address: ®r2 erg 0& Alt. Tel. No.: ikZ-813'9879 *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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $--- (, 11 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1)plicant Informatinn Name (Business/Organization/Individual): Address: City/State/Zip: ytl>F Phonew. %2F''3 2 --,9Se3% Are you an emplo or? Ch k th y G%.a appropriate box: 1. ❑ I am a employer with 4. 11 I am a general contractor and I employees (full and/or part-time).+ 2. ❑ I am a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurancecomp, insurance.$ 1We required.] 3. El am a homeowner doing all work 5 are a corporation and its officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance re d Type of project (required) 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.11 Plumbing repairs or additions 12.❑Roof repairs 13., ther t� quue ] 1 I t Any applicant that checks box #1 murt 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. tContractors that check this box must attached an additional sheet showing the new of the sub -contractors and state wh employees. If the sub -contractors have employees, they must provide their workers' comp- Policy number. ether or not those entities have I ani an employer that Is providing workers' compensation Information. insurance for nay employees. Below is thepolicy and job site Insurance Company Name: v Policy # or Self -ins. Lic. #: (Z $ C CCI q Expiration Date: { 3 / 0 Job Site Address:_/�'Z ( S�- Attach a copy of the workers' compensation policy declaration page (showing the policy number antic, ez ratio Failure to secure coverage as re expiration date). g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fore 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 coveraee virif;ra+;— Ido hereby certify under thepains andpenalties ojperjury that the information provided above is true and correct Si afore: Date: oz / O Phone #: ��Z� F — Officlal use only. Do not write in this area, to be completed by city or town offlclaL City or Town: Permlt/L!cense # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: ACORQ� CERTIFICATE OF INSURANCE ISSUE DATE 08/13/2007 PRODUCER MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC. 5949 Sherry Lane Suite 1300 Dallas, TX 75225-6532 (469) 232-2100 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. COMPANIES AFFORDING COVERAGE Company ACE American Insurance Company INSURED Climate Design Heating and Air Conditioning LLC S. Summer St. 5S ' Bradford, MA 01835 Company B Company C Company D Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement, term or condition of 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, conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO LT TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS OF LIABILITY A GENERAL LIABILITY ® Commercial General Liability ❑ Claims Made ® Occurrence ❑ Owners' and Contractors' Protection ❑ ❑ General Aggregate Limit applies per: ®Policy []Project ❑Location CGOG23723360 12/31/2006 12/31/2007 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE $ 1,000,000 MEDICAL EXPENSE $ excluded PERS. AND ADVERTISING INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 PRODUCTS AND COMP. OPER. AGG. $ see below A AUTOMOBILE LIABILITY Any Automobile ❑ Al Owned Automobiles ❑ Scheduled Automobiles ® Hired Automobiles ® Nan -owned Automobiles ❑ SCAH08227159 12/31/2006 12/31/2007 COMBINED SINGLE LIMIT $ 2,000,000 BODILY INJURY PerPerson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ COMPREHENSIVE $1000 deductible COLLISION $1000 deductible A WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY RSCC44458421 (Al States/Stop Gap Included) 12/31/2006 12/31/2007 WC Statutory Limit I X I Other EL EACH ACCIDENT $ 1,000,000 EL DISEASE Each employee) $ 1,000,000 EL DISEASE(Policy Limit $ 1,000,000 EXCESS LIABILITY ❑Occurrence ❑Claims Made EACH OCCURRENCE $ AGGREGATE $ A PRODUCTS/COMPLETED OPS. CGOG23723359 12/31/2006 12/31/2007 Aggregate Umit $ 10,000,000 Occurrence $ 3,000,000 $ $ $ CERTIFICATE HOLDER Town of North Andover Attn: James Diozzi 160 Osgood St. Building 20 Suite 2-36 North Andover, MA 01845 Pae SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF,THE ISSUING INSURER WILL ENDEAVORTO MAIL30 DAYS WRITTEN NOTICETOTHE CERTIFICATE HOLDER NAMED TOTHE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Authorized Representative •...411 .�y A 1 of 1 Certificate 10 # 1 STJRY2L No.: y a Date r r TOWN OF NORTH ANDOVER A BUILDING DEPARTMENT tl 9iOP`y1`an * 1 +�..o t Building/Frame Permit Fee $ SSACHUS� Foundation Permit Fee. $ 16 Other Permit Fee Building inspector * C? � • ' "� � Office Use Only 01 4e Cfnmm>Quu ult, of fassar4uBP#g Permit No. Mepartment of J1uhlir'_*afet1J Occupancy & Fee Checked —�— y - BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 1 3/90 (leave blank) 'w 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 TYPE ALL INFORMATION) Date _�L-4` . Q& or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) r-- 76 Owner or Tenant 49 G C CA! 4!�f Owner's Address Is this permit in conjunction with a building permit: Yes Z"" No ❑ (Check App erg ox) Purpose of Building 14 / Utility Authorization No Z a Existing Service Amps _/ Volts Overhead❑ - I Undgrnd ❑ No. of Meters New Service c.�, v Amps % - L gg Volts Overhead Lam— Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Worky vL ><+ SFr Lf r (' // S F.�O ✓ r C f' OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES C NO — 1 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 appy nate box. INSURANCE BOND —_ OTHER �_ (Please Specify) (Expiration Date) Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rough Final Signed under the Penalties of perjury: G FIRM NAME c ii Z & C iXl, C �` LIC. NO. 'J i!_ 3 Licensee 4-6-1 L, Signature �— LIC. NO. 2_L_k_r 3 /A Bus. Tel. No. Address �G �'� -V , i S �'Ly'� '7 eil00dAa Alt. Tel. No.�y w 6 Z de OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have 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. Own r Agent (Please check one) � ��^ Telephone No. PERMIT FEE S J �f (Signature of Owner or Agent) C-1 L # x•5565 .1 . Total No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ gr d. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners a Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of, Ranges No. of Air Cond. tons Initiating Devices No. of Sounding Devices No. of Self Contained No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Dishwashers I Space/Area Heating KW Detection/Sounding Devices Municipal Local ❑ Connection ❑Other No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW I Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES C NO — 1 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 appy nate box. INSURANCE BOND —_ OTHER �_ (Please Specify) (Expiration Date) Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rough Final Signed under the Penalties of perjury: G FIRM NAME c ii Z & C iXl, C �` LIC. NO. 'J i!_ 3 Licensee 4-6-1 L, Signature �— LIC. NO. 2_L_k_r 3 /A Bus. Tel. No. Address �G �'� -V , i S �'Ly'� '7 eil00dAa Alt. Tel. No.�y w 6 Z de OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have 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. Own r Agent (Please check one) � ��^ Telephone No. PERMIT FEE S J �f (Signature of Owner or Agent) C-1 L # x•5565 .1 . TOWN OF NORTH ANDOVER OFFICE OF THE TREASURER/COLLECTOR P. O. BOX 124 NORTH ANDOVER, MA. 01845 TEL: 508-688-9550 DATE: ' o)l _� 7 INVOICE TO: Q o- oJzl Dear Sir/Madam: Please be advised that your check 9 I issued on for $ Q) has been returned by your bank and cannot be redeposited. Under Chapter 432 of the Acts of 1989, Commonwealth of Massachusetts General Laws Chapter 60, Section 57A, the PENALY FOR TENDERING AN INSUFFICIENT FUNDS CHECK AS PAYMENT FOR A MUNICIPAL ASSESSMENT OR SERVICE IS $25.00. Please remit bank check in the amount of $ ) • W to redeem this item within fourteen (14) days. We will return your check to you at that time. Should you have any questions, please cail my office at the above number. Sincerely Kevin . :of Treasurer -Collector KFM/rm cc: No. Andover Police Dept.