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Miscellaneous - 99 MEADOW LANE 4/30/2018
I Rq MRA Tire Commonwealth ofilfarssackusetts Department of Industrial Accidents Office of Invesagagons L 500 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aoplieaat f®rmatio� Please Print LeObiv 1VaMe (Business/Organization/Individual): 1Y t '! j p'v-"794-1 Address: VWV- rL1, t LL MR. ° t83 hone #: 9-)D j - 7 4 7 t I . Are you an employer? Check the appropriate boas Type of project (required). 4. am a generacontractor and I 1: I am a employer with ❑ 1 l 6. New construction. employees (full and/or part-time).* :have hired the sub -contractors 2_ ElI am a sole proprietor or partner listed on the attached sheet_ 7. ❑ Remodeling ship and have no employees These sub -contractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Budding addition [No workers' cramp. insurance comp. insurance.t 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their l 1.E'Plumbing repairs or additions myself [No workers' comp. rieicof exemption per• MUL 12.[] Roof repairs insurance required.] ' c ra2,`§1(4}; and we 6aue,.no. I�- ❑ Other employees. [No workers' co'm ). insurance retired..] *Any applicant that checks box # 1 must also fill out the section below showing their workers compensation poucy mrurxnauUn. ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees_ If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the polrcy androb site information Insurance Company Name: )1�t! Policy # or Self ins. Lie. #: Expiration Date: O� - 2S '. l co lob Site Address: < l �cl Rte'' -1 CiLV/State/Zip: ti�-T� 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 fire 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby r the pains and pe dies of perjury that the information provided above is true and correctf012 5 Offcial use only_ Do not write in this area, to be completed by city or town official. City or Town: PermitfLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CityfUown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: - __ -- -_ Phone #:— DIVISION OF PROFESSIONAL LICENSURE a15$`3ftG� tr 'hf 7 1 -00 s SI��< Alli 11'�'J.m �X`ti .'Y.'_` ax .., .L",'i,! •...1il�,2uJi i- i 11.*.t �?3 ., .' 1 DIVISION OF PROFESSIONAL LICENSURE �Y...tl1J1C.JLkRb:-"''LS,JJ�pI"J WI i�f�3�" ��Pj'.li�iL'a7jlt1��JR� Sr��eJl API s R+ 1 7 r rig' AMY M ^;_i£7 ��. DIVISION OF PROFESSIONAL LICENSURE '✓`T�`ll�'1�yo . •.On wf {finn Date.. 2 1 ... 1.4 .................... ..... . .... .... . .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ............. t ............................... ...... 02 . . This certifies that ................................................... has permission for gas installation in the buildings of... at.................................................................................................. . North Andover, Mass. Fee.,........... . ...... Lic. N51�.�. ........ ..M.4w ...................................................... GASINSPECTOR Check #0KOq1I 9327 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover I MA DATE 5/22/2014 PERMIT # G lT JOBSITE ADDRESS 99 Meadow Ln OWNER'S NAME 1 GOWNER ADDRESS Same TEL—�FAXJ� TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONALE] RESIDENTIAL[j PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES® NOD APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace 1 Gas Meter x INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE 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 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 co liance with all Pertinent rovision of the— Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEJose h Marino LICENSE # 8736 SI ATtjqE MP El MGF ® JP ® JGF ® LPGI ® CORPORATION D# 3285C PART E HIP®# LLC ®# COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE = ZIP 01501 TEL508) 832-3295 FAX 508-926-4347 CELL 508-832-4614 EMAIL JMadno@RHWhite.com N W FF O z z 0 H U W P, a� Q z w a Z❑ z o }NEl W � ~ w o C W z F� a 4LLI v' ca w rj z a w a a o W d U) o a d a a � U x a. F a a � a iii = w W o � z z � 0 H U W a C x c� o x LU N ;TWO op >- EOLU w Nt LL 0 r—P > c- F— zd -0 Q � z U) it Lu �24 k4 Pi pip CERTIFICATE OF LIABILIW INSURANCE page 1 OV I OBE(MMIDDJyy7) THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BPS,OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this cartlfleate does notconferrights to the certificate holder In lieu of such endorsement(s), willim of Massachusetts, Inc. c/o 26 Conway Blvd. P. 0. Box 305191 X19hville, TN 37230-5191 R. H. White Construction Company, Inc. 41 Central Street P. 0. Boa 257 Auburn, MA 01301 INSURERA.- The Chaxtor Oak riXA Insurance INSURERS.Trava:tArg property Casualty Co! INSURER C: Nati=Al, Union Fire Inauranca NSURERD; Travelers Ind=nity Cormanv 38-46772378 NAICrt jayl25615-00119445-001 25659-001 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA7ED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R A I GENERAL LIA6ILITY IMFRCIAL GENERAL LIABILI7Y CLAIMS -MADE OCCUR APPLIES PER; B AUTOMOBILE LIABILITY ALI.OWNED SCHEDULED AUTO$ AUTOS NXANYAUTO HIRED AUTOS X NON•OWNED Cv Dad AUTOS g Cv11CUMBRELLA LIAR I >� OCCUR PJCCESS LI I(— CLAIMS -MADE DED I V RETENTION$ 10.00 977X9948-13 19/1./2013 1'9/1/2014 IEACrl MED 977K955A-13 9/1/20.13 9/1/201.4 LIMITS INJURY BODILYINJURY(Perpemon) $ BODILY INJURY(Peraccidon!} (5 BE8766140 19/1/2013 19/1/2014 D WOREMPLOES'LI COMPENSATION `,,TRFUB B205A185-13 9/1/201.3 9/1/2014 AND EMPLOYERS' LIABILITY YIN D ANY PROPRIETORIPARTNERIEXECUTIVE NrA VTC2KUB A20gA71A-13 OFFICERIMEM9/1/2013 9/1 /3014 BEREXCLUDPo7 F+�"J( 1Myendstmvrn NH} uE4SUnnB I luN uF QFERATIONS bslew Mvidence of Inaurance DISEASE -POLICY LIMIT Bosco 2.000,000 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE C001:4197604 Tp1:1694012 Geat:20267680 ©1988-2010ACORD CORPORATION. All rights reserved. CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Date. ".� °T� �►O L---�TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ` ,SSACMUS� . This certifies that�i /x2.��/. ••• •••••••••••• 11a has permission to perform�.'� ,.......... • ...... plumbing in the buildings`Of ..... L.!? 0 ! .f ..................... . at .,'.'e. i ....... ,North Andover, Mass. �:� Fee.././..... Lic. No.. �.?/.� . ........ ../.i ........ . PLUMBING IN4E*C*TOR Check # �l 3 + woo V MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS jj y Date �" 7, 05' Building Location DOW 004MC, Owners Name 1k1 la Permit # [i Amount O Type of Occupancy AGuz-A1✓1�' G New ❑ Renovation 0 Replacement FIXTURES Plans Submitted Yes❑ No (Print or type) / Check one: Certificate Installing Company Name /CJ)Lo AA' 11-024� �L� `I,GiL❑ Corp. Partner. 5'0�Fico. Name of Licensed Plumber. /_1LJr rzAly'. b Gr Insurance Coverage: Indicate e t pe of insurance coverage by checking the appropriate box: Liability insurance policyIT Other type of indemnity ❑ 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 Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa%usetts State Pmbing Coded Cl �je x142 of the General Laws. JBy' City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License rc n e Numver Master Journeyman u ❑ Date ..f........ . ..r ,AORTI{ Of .00 .6. ,tiO TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that .. .. c.. < l� c•....;! (-"/- ................. has permission for gas installation ..., .� +! �.� ................. in the buildings of ..../ . C-. ? ................................. at � ...... , North Andover, Mass. Fee. .9 °. ... Lic. No. .6F ?. ! .... /GAS INSPECTd Check # : it 5226 MASSSACHUSErIS UNIFORMAPFUCATONFORPERNUrTODO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date GJ "0 � 1. e.5— Building Locations A gA 13 did Permit # C Amount $ 3 6 Owner's Name New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or type)-� Chec one: Certificate Installing Company Name Z4Aasii%2 h�. �U '' !/t 9� /I/ 37 ❑k Corp. Address •-�� A,41z;�v8r D D ❑ Partner. usess a ep one �irm/Co. m Name of Licensed Plumber or Gas Fitter 11seA1 b INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy ElOthertype 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ t. _o►.., , o.,;f., that an nf rhe dmaik and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with ail pertinent provisions of the Massachusetts State Gas C de and Cha r 142 of the General Laws. ICity/Town (APPROVED (OFFICE USE ONLY) Pignature of Licensed Plumber Or Gas Fitter lumber P2-,,,3 Gas Fitter tcense Number Master ❑ Journeyman 12ND. FLOOR (Print or type)-� Chec one: Certificate Installing Company Name Z4Aasii%2 h�. �U '' !/t 9� /I/ 37 ❑k Corp. Address •-�� A,41z;�v8r D D ❑ Partner. usess a ep one �irm/Co. m Name of Licensed Plumber or Gas Fitter 11seA1 b INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy ElOthertype 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ t. _o►.., , o.,;f., that an nf rhe dmaik and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with ail pertinent provisions of the Massachusetts State Gas C de and Cha r 142 of the General Laws. ICity/Town (APPROVED (OFFICE USE ONLY) Pignature of Licensed Plumber Or Gas Fitter lumber P2-,,,3 Gas Fitter tcense Number Master ❑ Journeyman 6061 1 Date ... e / .:° ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ^-^ 1....'4 " .:.......... has permission to perform ... ....................................... wiling in the building of ...........�-.; ..................................................... �n at ..7�.. 7 ............................... '................ ,North Andover, Mass. Fe63S.. 0......... Lic. NJ Z'71h ... ............ ELECTRICAL INSP � . Check # DERAMWOMAXSUM 60 BAARDo1FF=PAEVCN1wR&ZGtT1g1 m7C1wa* �'"tt tvo ,� . �P�y � Hep Checked APPUCA71ONFOR PERARTTO PERFORM AHL WORK M BE FEMRMBD R1 ACCORDAHM WITH nE MAWACHN m mxcrF (PLEASE PR W IN INK OR TYPE ALL PMRMATION) Town of NoRh Andover The undersigned applies for a permit to Location (Street & Number)` Owner a Tenant I C Owner's Address %a' Is this permit in conjuncts ith a bui Purpose of Building Existing Service Amp Amp / Volta Number of Faders and Ampacity Location and Nature of Proposed Electrical Work f GU WORK 527 CMR 12:00 Date To the Inspector of Wires: (Check Appropriate Box) Utility Authorization No. No. of Meters No. of Meters Na of Liswing outlets Na of Hot Tubs f, Of7Ferrlorrnsn TOW KVA Na of Liabdog Fie tares Swimaove dna Pool' Ab Bebw OsaentaA KVA Na of Receptacle Outlets Na of OB Burners Na of 8rne1110114.7 Liahtina Battery Unita Na of Switch Outlets No. of Oas Burners FMZ ALARMS Na of Zones Na of Rang Na of Air Cand. Tam Na of Deactim and No Dispaale J Na of Hat TOW TOW /P01110 Tose KW laitiadng Dam Na of Soamdng Dovka No. of Dishwahsrs Space lees Heating KW / No. Of SWCUAWned a' Na d Drym Heating Donnas KW Lmd Madelpd Camecrdorta Od —� No. of Weser Heaton KW Na Of Na Of 311100 Bsilesis Na Hydro Massae TAA Walt- TOW HP kteteanae0;r�¢ Pltst>.tbleteg�ierle�dll�liieedialQQmlLaoYa ]MeaaaeitLialab►itsttsrresl�iryndudrBt�rnpitb tayssttteOrskltt�ititalst Yo ED ND Itsivezhftdveidpsddumrofe0mm YM Iymltated dwdyKPkashkft9eg'RdWywVby B [3 am 0 � EstrnebdVals: d&c"W* S �Ia i�etsiortDstiRet�ttsbd Ram p� F�tMNAM UWWNQ U=No c V:j aofne.Tblrla y t o7 e AkTdNa (JWI�iL'S WAIVER;I��selsKlheLicatee���lheiriasslneeo�a�arktsUhl�ilegiivalmtattac}i�edbjlNae®dsa�Gcr�ILawB andtl�rrpsq�zmfNept��pic�iwai�afiue4ilt�t (Please chtxJr one) Owner � Agent ' TOphtme No, MMM FEEallpaium of Uwner of AIM D@lUQIWff0FPtUXSV= per dt 8oA V0FF=PNVMWUMLA1MM7C1 RjZS r, oaCapsney & Fees Chocked ...... APPUCATTONFOR PERMUTO PERFORM CAL WORK ALL WORK.M es PEWRMDD IN ACtARDAMM Nall THE MASSACHUSM tBWnWAL oDlb 327 CMRw 12:00 ' w (PLEASE PRDVT, OR TYPE ALL IN�AMA,1401Y .. . � Town of North Andovar To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described bel • Location (Street & Number) L� owner or Tenant owner's Address b this permit in conjunctio�th s 9ding perms YesIM No a (Cheek AWoprift Bon) Purpose of Building 9 u`f'--YlJ LCAV It -t—'i J Utility Authorization No. Existing SarviceQ� Amp -' I olts Overlied Underpound No. of Metas New Sa3avia Ampex olts Ovedrad Underpound No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Na of Li0ft 06" Na of Hot Tabs W Of Trandorm es Tod KVA Na Of Liabdq Ruffle Swimmt Pod' Above Below �� KYA Na 7 Rwgtwb oudett Na of OB Barents Na of Ero gNxy Liandna BBWgr hair Na of Swfsn6 Ontlas , Na don Harms Na of BMW Na of Air Cad. Tad FIRE ALARM Na d Imes Toss No of 1151008010J Na d Had ToW Tool Na d Deacdon sad /Pamll Tor KW b1fleftsDevim No. of Dishwulam Spm Ara Hestina KW Na of Devices Na dSBNcanWrrd Na d Dryes psi KW DOISMIGNIonaftll Locd Davkn 0MWcipde 0 odwCommdon— No. of WsW Hostas KW Na or Na of 311011 Bdbi No. Hydro Manage Tops Na of Motors Told Hp '=010110CINZ YM Li I BCNDr am s /, slat yoQ, M r)rhrtecttedmtYK pkWirioalteg'pedaomVbl ANIC404h r ENftU edVdteafEbC dariWct S �l Find Lio=Niti a - , �Q �Biaine.'1btNa y l 07LX arddtiarrwsiaAncinlipemktppicsim 1i,egmi00101 - T ---- `'•.•�••�"•'�i•••+"'• (Please check one) Oerner A,erlt T . o-' elephone No. ��*r' Fly � �� Location / L7 �'l�°AdOW Z/J No.S Date C/— 'd �OR,h TOWN OF NORTH ANDOVER A Certificate of Occupancy $ '� s'•^° E��' Building/Frame Permit Fee $ �cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 37 7 18534 t Building Inspector i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT A ONE OR TWO FAMILY BUILDING PERMIT NUMBER: r DATE ISSUED: �S ` , C) S �/ C SIGNATURE: . / V I 'A X Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number �\ Pt(dl0\)� .1 M f) O l� ' 1 11.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Re4qWred Provide Regaired Provided Required Provided 1.7 Water Supply M.G.L.C.40..._ 34) ' Public ❑ Private ❑ Zone I.S. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System 0 SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT 110LUIIli tJ1SLrlU1: T8S NO 2.1 Owner of Record (Yl 1 cvj- � �loi r Meade U(1 1N), Pn Name (Print) Address for Service: q --n Signature 2.2 Owner of Record: �� r t 010 �)C) V n -C-� Print Telephone Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: �— Ad % Signature Telephone VU 3.2 Registered Home Company Name Address Not Applicable ❑ 00S2y3 License Number -5.Z4,-�� Expiration Date Not Applicable ❑ Registration Number Expiration Date C-* SECTION 4 - WORKERS COMPENSATION (RG.L. C 152 6 2506) 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 all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolitiori ❑ Other ❑ Specify Brief Description of Proposed Work: - SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFICiALUSE ONLY `.' 1. Building C5 (a) Building Permit Fee Multi Tier 2 Electrical t� � ' (b) Estimated Total Cost of Construction 3 Plumbing 6 O Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATI N' TO BE COMPLETED WHEN OWNERS AGENT OR APPLIES FOR BUILDING PERMIT `CnONTRACTOR l '1 I> \Mek' )o -y _, as Owner/Authorized Agent of subject property Hereby authorize Dgyc 1 1 .S CW P� to act on behalf,_' all atte , relative to work authorized by this building permit application. j Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, C 1 t ►� ft)CA / D'(- i'l 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 beliie'f`(\. , Print Name Signature of Owner/Agent ) NO. OF STORIES Date 11i� t SIZE BASEMENT OR SLAB S17 -E OF FLOOR THVIBERS 1 2ND 3RD SPAN DIMENSIONS OF S111S DR14 NSIONS OF POSTS DRvIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Deportment of Industvid Accidents Offiee of Investigations 600 Washington .Street Boston, MA 02111 www.massgov/die Workers' Compensation Insurance AMdavit: Builders/Contractors/Electrid2mffllumbers Addres$/.- City/State/Ziw Phone #• ? S9,7 -e701 Are you as employer? Check the, appropriate box: I. ❑ I am a employer with 4. ❑ I am a general contractor and I ,�, Vloyees (full and/or part-time).• have hired the sub -contractors 2. IY'I am a sole proprietor or pareses- listed on the attached sheet ; ship and have no employees These sub-eontractoTs have working for me in any capacity. workers' comp. insurance. (No workers' comp. insurance 5. ❑ We are a corporation and its required.] oflrcers have exercised their 3. ❑ 1 am a homeowner doing all work right of exem*ion per MGL myself. (No workers' comp. c. 152, § 1(41 and we have no insurance required.) t employees. [No workers' cOMP. insurance required.] Type of project (required): 6. ❑ construction 7. Ld emodeling S. ❑ Demolition 9. ❑ Building addition 10-Ef Electrical repairs or additions 11.❑ Plumbing repairs or additiom 12.❑ Roofrepairs 13.❑ OMer -PMY 6MMMIS v % GUFMN OWl it 1 UMN MM U11 ow MV iCum Below M0vM9 2wif w*fkM'G0MP0Uwd= po&7 mfim=fim- t Homeownen who subuit this alBdsvd they ae delta an Mak and then hue Outride eouhactca mud subnit • sew affidavit "cahina suck tCono wbi dwt Bieck this box mwt attached an additional sheet showing the Haus of the sub-mbuctm and their woken' temp• policy information. I ani an ernpkyn that is provldlna workers' Compensation Inswnnee for my eMPIVYM Below is the pallty MdJob ske Informadm Insurance Company Name: Policy # or Self -ins. Lic. M Expiration Date: Job Site Address: City/Statozip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and espiration date). Failure m secure coverage as requir�Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to E 1,500.00 and/or one-year % 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 ID the Office of Investigations of the DIA for insurance coverage verification. I do herby cc under t pains and nahies o ury that the InfWwwdon provikd abbore is erne and eo CZ Si Date. OfflCid use only. Do not write In thb area, to be con p/eted by c4 or rowno�7cla1 City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License 6 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone 0: 11I1Vl aaaativiia saaa%s XJMO%,a %,arravaa Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their en>ployees."1 Pursuant to this statute, an employee is defined as ...every person in the service of another under any contract of hire; pry' . express or implied, oral or written." An employe' 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 all 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 emploYa•" MGL chapter 152,125C(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 hu not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,125C() 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 d Please fill out the workers' compensation affidavit completely, by checking the boxes that apply nt your situation and, if necessary, supply sub-couractor(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 parmers, are not required to carry workers' compensation insurance. If an LLC or UY does have employees, a policy is required. Be advised that this affidavit any be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be an 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 Deparmnent of Industrial Accidents. Should you have any questions regarding the law or if you an required to obtain a workers' compensation policy, please call the Department at the 1 1 P listed below. Self-insured companies should enter their self-insurance license mnnber on the appropriate line. City or Town OAlciab Please be sure that the affidavit is complete and printed legibly. The Department bas 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 applicauL Please be sure to fill in the perznMiceese number which will be used as a reference number. In addition, an applicant that must submit vink ple pernnVhcense 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 � been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid a 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 burn leaves etc.) said person is NOT required to complete this affidavit t 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 can. 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. # 617-727-4900 east 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26.05 wwwmass.gov/dia PROPOSAL NO. SHEET NO. DATE PROPOSAL SUBM TrED TO: WORK TO BE PERFORMED AT: N - ADDRESS ADDRESS CITY, STATE CITY,STAATrrE�o < DATE OF PLANS PHONE NO. _ ARCHITECT We Ireby propose to tprnish the erformthe labor necessary f r the comple ti of % ," r °I r is✓ 1 _ ® A 02 7-1 All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: Dollars ($JCIR—) with paymen to be as Bows A IS n ® J/ C / - 5 l a�o vae�ca one nng �xra costs f�espeCtfully bm�1tC0 ar a �wMA will be executey upon n cm , and wlll became an extra cnarge Any attat ons:ay�%beyondont aver anc awo testimate. A':I omens eoningonl upon b1n{Ws. Per— � ft—dens, o! f er Note Note - This proposal may be withdrawn by us if not accepted within__ days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. SIGNATURE �. DATE SIGNATURE— _ 1� 945A DE VELLIS CARPENTRY QUALITY WORKMANSHIP RESIDENTIAL • COMMERCIAL Peerless �ICS:V i id islXf,q''�!.wd S:r., (i PREPARED FOR: DAVID DEVELLIS PRESENTED BY: INSURANCE SOLUTIONS CORP POLICY PERIOD: EFFECTIVE DATE: 08-27-2005 EXPIRATION DATE: 08-27-2006 QUOTE NUMBERS INCLUDED: ACCT 3001242325 CCP 3001242337 "This Quote Proposal has been developed solely as an estimate of premium for the listed coverages shown, based on the information provided to the Company, and all amounts shown herein are subject to change. This Quote Proposal does not bind or provide actual coverage and is not an offer of insurance. Specific terms of coverage, exclusions, and limitations are contained solely in a completed insurance policy issued by the Company,to a named insured and for which a premium has been paid. ACORDb BUSINESS OWNERS APPLICATION INDIVIDUAL DATE LIMITED CORPORATION GL CODE SIC 08/11/2005 PRODUCERPHCON E (603)382-4600 COMPANY TOT SQ FT AREA JOINT VENTURE NAIC CODE $ VALU- ATION: Peerless Insurance Company SQUARE FEET CORPORATION $ INSURANCE SOLUTIONS CORP COMPANY POLICY OR PROGRAM NAME PROGRAM CODE: MAILING ADDRESS (INCLUDING ZIP+4) CONTACT FOR INSPECTION PHONE PO BOX 1079 DISTANCE TO [CREDIT BUREAU NAME ID NUMBER NH -001 -SUBCONTRACTED WORK IN CONNECTION WITH CONSTRUCTION, REC 91581 $ 9000 C CLASS 09 TERR 001 ACCT# 3001242325 CCP Quote Number# 3001242337 YES NO ATKINSON NH 03811 I BASEMENT PRESENT? YESNO R PROP X NEW RNW EFFECTIVE DATE 08/27/2005 EXPIRATION DATE 08/27/2006 FVRC DIRECT BILL AGENCY BILL PAYMENT PLAN CODE: 8110367 SUBCODE: AGENCY CUSTOMER ID ff 7.5g QUOTE ISSUE POLICY POLICY TYPE YES DEPOSIT NO WIRING BOUND (DATE): STD SPEC X OTHER $ APPLICANT INFORMATIdN NAME (First Named Insured)X David Devellis INTEREST INDIVIDUAL SURROUNDING EXPOSURES & OTHER OCCUPANCIES LIMITED CORPORATION GL CODE SIC FEDERAL ID # 198 MAIN ST DEDUCTIBLE PARTNERSHIP TOT SQ FT AREA JOINT VENTURE TENANT $ VALU- ATION: YEAR BUILT SQUARE FEET CORPORATION $ OTHER 2000 402 ANY AREA LEASED? I YES I X NO MAILING ADDRESS (INCLUDING ZIP+4) CONTACT FOR INSPECTION PHONE RATE DISTANCE TO [CREDIT BUREAU NAME ID NUMBER NA I UKL UI- I3UJINt,1 __JOFFICE RETAIL APARTMENTS RESTAURANT 'H YRS IN CLASS CODE RATE # RATE GROUP HBUS SERVICE WHOLESALE CONDOMINIUMS CONTRACTOR 25 91341 # OF EMPLOYEES HOURS OF OPERATION ANNUAL SALES/RECEIPTS TOTAL PAYROLL 1$50,000 $ DESCRIPTION OF OPERATIONS/ Interior Finish Carpentry OCCUPANCY PREMISES ADDRESS1 HECK IF PRI- PREM #: BLDG #: 1 X C (Street, City, State) MARY PREMISES INTEREST AREA OCCUPIED SURROUNDING EXPOSURES & OTHER OCCUPANCIES PERCENTAGE RC X OWNER ACV 198 MAIN ST DEDUCTIBLE 100% TOT SQ FT AREA BLDG TENANT $ VALU- ATION: YEAR BUILT SQUARE FEET SANDOWN NH $ DEDUCTIBLE $ NONE % AppLICABLETO: 2000 402 ANY AREA LEASED? I YES I X NO PERS PROT RATE DISTANCE TO FIRE DISTRICT/CODE NUMBER INSIDE CITY LIMITS? NH -001 -SUBCONTRACTED WORK IN CONNECTION WITH CONSTRUCTION, REC 91581 $ 9000 C CLASS 09 TERR 001 HYDRANT FIRE STAT FT MI UNITS STORIES YES NO COUNTY: Rockingham Zjp: 03873 IdrLUd.4WFA LIABILITY lChnnsa the limit nntinnc r-mmnatihip with the nrnnram vnir ara rnnuaatinnl COMBINED SINGLE LIMIT $ LIMIT % COINS HIRED AUTO $ included RC $ $ ACV INFL % DEDUCTIBLE CONSTRUCTION TYPE TOT SQ FT AREA BLDG $ $ VALU- ATION: $ FVRC $ DEDUCTIBLE $ NONE % AppLICABLETO: $ Frame % APPLICABLE TO: PERS LIMIT %COINS VALU- (S) gross sales - per $1,000/sales (P) payroll - per $1,000/pay (A) area - per 1,000/sq it (C) total cost - per $1,000/cost (M) admissions - per 1,000/adm (U)unit - per unit (T)other RC NH -001 -SUBCONTRACTED WORK IN CONNECTION WITH CONSTRUCTION, REC 91581 $ 9000 C ACV DEDUCTIBLE UNITS STORIES SPRNK I BASEMENT PRESENT? YESNO R PROP $ 13,000 ATION: FVRC $500 1 7.5g IS IT FINISHED? YES NO WIRING ROOFING PLUMBING HEATING ROOF TYPE BLDG CODE TAX CODE WIND CLASS BUILDING YEAR YEAR I YEAR YEAR GRADE COMM I IMPROVEMENTS SPECRESISTIVE SEMI- OTHE LIABILITY lChnnsa the limit nntinnc r-mmnatihip with the nrnnram vnir ara rnnuaatinnl COMBINED SINGLE LIMIT $ $ HIRED AUTO $ included BODILYINJURY& OCCURRENCE $ 1000000 PROFESSIONAL LIABILITY PROP DAMAGE AGGREGATE $ 2000000 LIQUOR LIABILITY $ $ NON -OWNED AUTO EMPLOYEE BENEFITS $ included $ MEDICAL EXPENSE PER PERSON $ 5,000 $ $ FIRE DAMAGE $ 50,000 $ $ DEDUCTIBLE $ NONE % AppLICABLETO: $ % APPLICABLE TO: CLASSIFICATION CLASS PREMIUM BASIS BASIS (S) gross sales - per $1,000/sales (P) payroll - per $1,000/pay (A) area - per 1,000/sq it (C) total cost - per $1,000/cost (M) admissions - per 1,000/adm (U)unit - per unit (T)other NH -001 -SUBCONTRACTED WORK IN CONNECTION WITH CONSTRUCTION, REC 91585 C $ NH -001 -SUBCONTRACTED WORK IN CONNECTION WITH CONSTRUCTION, REC 91581 $ 9000 C NH -001 -CARPENTRY - INTERIOR 91341 $ 24500 P PRIOR POLICY IE5 /LOSS HISTORY I I See attached loss summarV PREVIOUS CARRIER POLICY NUMBER TOTAL PREMIUM EXP DATE # LOSSES TOTAL LOSSES LAST 3 YRS DESCRIPTION OF LOSSES, WHETHER OR NOT INSURED (Date, cause, amt paid, claim status) AGORD 160 (7/98) PLEASE COMPLETE REVERSE SIDE O ACORD CORPORATION 199: CA m m m N m v m v■ H d Cie � d 'C o CD az y CD o ns . 6 5i o CL y ac 30 o CD o CL cr m co CD O C CDCD y� �■ av y O C S v CO) O 'o Z CD O CD CD 0 '400 M ) 2� 0.o cmti C m o we t7 n ��� m � Z �co 0. rt� ?=.n.►=m O y m o•� o L4 C*'= m = o G► mom: a m omPk 0 EEO ?MWc W �Om ips — cc � a aom a (/)WA R C/)m m• tCOL n yam: o m O N d ? Q EL Z m :�� o - \-J y.�C ,..► IE o H coo cmp 0 o OWN`- m y Cl) O 1 z � � m ny i 1 ' Rm�• m . p ' F ocn m w C0 �s �? o rr d � oC, if. 1 r�� :C CLW o 0 CD omi 0 9 s O C z w x w Crf � . �- 'd r w to �. tv O omi 0 9 s O C Date.//. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that ................... has permission to perform...... D. t: r ........... plumbing in the buildings of k.0 ....................... at ........ North Andover, Mass. Fee. 3.2. Lu. No... .t.A. ....... ,PLUMBING INSPECTOR Check# 5789 MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING (Print or Type) �, Mass. Date 20 613Permit #Building Location(l/�1(�LiOwner's Name /� ��/S Type of_ Occupancy _ l LSSI New ❑ Renovation 11 Replacement fY Plans Submitted: Yes ❑ No ❑ FIXTURES B.P. # `SEWER # cp=r Installing Company Name Address_r�L )% S Check one: Certificate ❑ Corporation Business Telephone�� �� 0 Partnership �'Fi �r rmlCo. Name of Licensed Plumber or Gas Fitter � lj til -mf' INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes JD— No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy. ❑,-�— Other type of indemnity ❑ ' Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performedydRpermit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and 2 of a General Laws. 13y Sig t7u o License umber Title City/Town APPROVED (OFFICE USE ONLY) Type of License: ❑ Master ❑'dt1'Meyman APPR License Number D=/ 0 D • • MEe������i���������� MME 0�� ME M ME M M ME MEN MEN M MMMMMMMMWMMMMM NINE Installing Company Name Address_r�L )% S Check one: Certificate ❑ Corporation Business Telephone�� �� 0 Partnership �'Fi �r rmlCo. Name of Licensed Plumber or Gas Fitter � lj til -mf' INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes JD— No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy. ❑,-�— Other type of indemnity ❑ ' Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performedydRpermit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and 2 of a General Laws. 13y Sig t7u o License umber Title City/Town APPROVED (OFFICE USE ONLY) Type of License: ❑ Master ❑'dt1'Meyman APPR License Number D=/ 0 D Date.//-.. �. C ... . A,pN TM ,,; ,°ti° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that. has permission for gas installation ..., in the buildings of ../ at P r! ....... . , North Andover, Mass. Fee. .� i. .''. Lic. No. 2 Y. f! &1.. ... GAS INSPECTOR Check # 7 L 45,,7 C- 55ACHU.SETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) 42 , Mass. Date r 20 Permit )~� Building Location owners Name --N 0/, Type of Occupancy �� [s� New❑ Renovation ❑ Replacements Plans Submitted: Yes ❑ No ❑ Installing Company Name k L 47-1� Address I E 0—WT S F l Check one: Certificate corporation /,a.6 C Buslness Telephone 01? �/ ���� 3 ❑ Partnership Name of Licensed Plumber or Gas Fitter 0,6E CALL /�/j am IrnvCo' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MCL Ch. 142. Yes ,per" No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. .` A liability Insurance policy Q---' Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mats. General Laws, and that my signature on this perml lication waives this requirement Signature o wneror Owners Agen Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted for entered) In above application are true and ac ate to the best of my knovNedge and that all plumbing work and Installations performed under the permit Issued for this application vii a in compliance with all pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of the Gene I laws. Type of License: By ❑PlumberS n o L censed Plu er or Gas Fitter Tian &G -2-S f I tter cityrrown Master License Number - `7 APPROVED (OFFICE USE ONLY) ❑ Joumeyman • • i • i • .. i • � • Installing Company Name k L 47-1� Address I E 0—WT S F l Check one: Certificate corporation /,a.6 C Buslness Telephone 01? �/ ���� 3 ❑ Partnership Name of Licensed Plumber or Gas Fitter 0,6E CALL /�/j am IrnvCo' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MCL Ch. 142. Yes ,per" No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. .` A liability Insurance policy Q---' Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mats. General Laws, and that my signature on this perml lication waives this requirement Signature o wneror Owners Agen Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and Information 1 have submitted for entered) In above application are true and ac ate to the best of my knovNedge and that all plumbing work and Installations performed under the permit Issued for this application vii a in compliance with all pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of the Gene I laws. Type of License: By ❑PlumberS n o L censed Plu er or Gas Fitter Tian &G -2-S f I tter cityrrown Master License Number - `7 APPROVED (OFFICE USE ONLY) ❑ Joumeyman Date. / (% .. !. ` ,c ? o'<"•O , 4, TOWN OF NORTH ANDOVER 3?oL o PERMIT FOR PLUMBING i i, a SSAcwUS� This certifies that ............................... has permission to perform ...........//.��............................. plumbing in the buildings of .. ! ? �... (.f'!�`.�............... . at ....... , North Andover, Mass. Fee.Lic. No.. .. ....... i PLUMBING INSPECTOR Check # 1 3 it -5740 a ?_o MASSACHUSETTS UNIFORM -APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Date 2D- 63 Permit #� CfU Building Location_ 19 We Owner's Name Type of Occupancy /� &S /v New ❑ Renovation ❑ Replacement -G— Plans Submitted: Yes ❑ No ❑ B . P . # SEWER# FIXTURES SEPTTC# Installing Company Name: 90 N /Gh: P -1-1 - Check one: Certificate # Address i`, �-' Ube � S r, ❑ Corporation ❑ Partnership Business Telephone_ C -/-)C, C/-) Name of Licensed Plumber ' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes E--.. No ❑ If you have checked+Les, please indicate the type coverage by checking the appropriate box A liability insurance policy [:I-- Other type of indemnity 13 Bond ❑ 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 Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perform der the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Co apter 42 neral taws. Title Signatur o� �-`sed Plum City/Town Type of Lice se: Master ❑ Journeyman,0--- APPROVED OFFICE USE ONLY) License Number N N z N z X o z . _z C �_- W X J t!1 Q V F' N O � N cn Z to C¢ 0 N W N h- w N Cr F- x U ¢ .� _z C to O W _ z w _ 0. v + U ¢ m Z ¢ y w t F- to z G a 0 C —< O W O ¢ w F- w d to ¢ < w J -- !� p C ¢ 1-' (n J < Z X ¢ a ¢ U- C� i- y o= y = a o Wz z '� X= Q) LL n< 3 c m p 0 SUB—BSMT. '1 BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name: 90 N /Gh: P -1-1 - Check one: Certificate # Address i`, �-' Ube � S r, ❑ Corporation ❑ Partnership Business Telephone_ C -/-)C, C/-) Name of Licensed Plumber ' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes E--.. No ❑ If you have checked+Les, please indicate the type coverage by checking the appropriate box A liability insurance policy [:I-- Other type of indemnity 13 Bond ❑ 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 Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perform der the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Co apter 42 neral taws. Title Signatur o� �-`sed Plum City/Town Type of Lice se: Master ❑ Journeyman,0--- APPROVED OFFICE USE ONLY) License Number t C7 z a � z N m 0 -4 O m x 0 0 m N N 2 N m 0 -4 O z N N T 7C r z m 0 r m m O a -t D m m -c � T m v m O T ? r m v II7 c O O a -� m Q � r Z L 'n z D r c D O 'n � z z o m o � m O C � 0 N o m 0 N 0 � z r r - O .� v z x 0 0 m N N 2 N m 0 -4 O z N N 7C m 0 N a � T m v m ? r � v O r Z L 'n b 4 O 'n � o m o O C � N o m 0 0 � z r r - C .� v z x 0 0 m N N 2 N m 0 -4 O z N Date.. f�. r.,.:.. /�.... NORTH TOWN OF NORTH ANDOVER ��tt lE� .610 '��� p PERMIT"F_OI�VA'e ^INS ALLATION 9SSACHUSES This certifies that .......t . ..... .......... !.. ............. . has permission for gas installation. -.'X ,! J r ; ' 11 in the buildings of ........: .. +........... ! ........... . ... North Andover, Mass. .......:.....'....°......... GAS INSPECTOR' WHITE: Applicant 'CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) - = o M N N C M: . 0 U. NORTH ANDOVER Mass. Date—&o L/' �,_ 19j City, Towndy Permit # 50 �Klo-72 (; Building Owner's_ I AT: Location fa Name New �. Renovation ❑ Plans Submitted Yes ❑ No Type of Occupancy: Replacement ❑ j: 1 • • ' (Print or Type) Check One: Certificate Installing Company Name _AAZTIQlML�� 4L rvn ❑Corp. Address -S f�,S W p v L> l�lL ❑ Partnership _ 4/oIR--T-f-L 4.N D c, )z __�tlf.� ��,�! � 01�irm/Company Business Telephone Z.�W .'�.i Name of Licensed Plumber or Gasfitter 1 hereby certify that all of the details and information 1 have sui;mitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 141 of the General Laws. M Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Plumber — 1 Gasfitter Signature of Licensed Master b`r 0, itter Journeyman icense er 10010mommommm MEN Nora am No • • • ' ■..... ■.... . NINE. ■....�,■. ■.. ' • • • ■.■�■.■■.....■...■... �..■�... • • ■■■■■..■■...■■■■■..��... NEIN■ • • EINE.■.. NEIN. �....�■.......... MW ............ NEIN �........... (Print or Type) Check One: Certificate Installing Company Name _AAZTIQlML�� 4L rvn ❑Corp. Address -S f�,S W p v L> l�lL ❑ Partnership _ 4/oIR--T-f-L 4.N D c, )z __�tlf.� ��,�! � 01�irm/Company Business Telephone Z.�W .'�.i Name of Licensed Plumber or Gasfitter 1 hereby certify that all of the details and information 1 have sui;mitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 141 of the General Laws. M Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Plumber — 1 Gasfitter Signature of Licensed Master b`r 0, itter Journeyman icense er W W a r O Z i 4 i o o ' V f„ 0. V _z ; W Q C7 s ' � Z � N W (7 O � i a W W a r O Z i 4 ac o r ' V W 0. _z ` N Q C7 s ' N2 1 ,38 Date.. 57/..:C}. !... It TOWN OF NORTH ANDOVER PERMIT FOR WIRING r R hh - - W.y 2 This certifies that ..... . Q:.,J.�. ..... .�.... ��c..:.... has permission to perform ..... ..R.��[,r..s�.nP... �.......l tj... ......... ........ wiring in the building of .... C. .VA -re .. .......................... ......................... at ..... ...5/�1/... 8.1.er-l- .KV1.............. , North dover, Mass. Fee....- :..Lic. No. l.. ••............................................................. ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer eOWNME4d7� 07 7X455Xe;;WS5775 Dir,4 P«" Sk�dq BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only Permit No_ _I! Occupancy & Fee Checked 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) Town of North Andover The undersigned applies for a permit to perform the electrical work described ,below. Location (Street & Number / 9 ��<� �-�7�� Owner or Tenant 66OETI Owner's Address �, IV62yalo 2-,14f To the Inspector of Wires: Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity, Location and Nature of Proposed Electrical Work OTHER: T/L�// '" V6"� � —h1V5 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) l– `� (Expiration Date) Estimated Value of Electrical Work$ Work to Start 1--'g_ iY Inspection Date Resquested r/Ir'`7F Rough Final Signed under the PerVgles of perjury: dcyt, LIC. NO. l G FIRM NAME /�/�f/1/� �C'7,�1G4C2 ����—,,q NO. Bus"Tel No.Z- Address C� �7'``/b ✓/ 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 $�-- (Signature of Owner or Agent) Total No. of I-ight8ng Outlets No. of Hot fuse No. of Transformers KVA l Above ❑ In ❑ No. of Lighting Fixtures . Swimminq Pool gmd ❑ gmd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlet No. of Oil Burners Ba Units No. of Switch Outlets No of Gas Bumers FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices . Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices Nod of Self Contained No. of Dishwashers Space/Area Hearin KW DetectionlSounding Devices ❑ Municipal ❑ Other No. of Dryers Heatin 0 KW Local Connection No. o No. of Low Voltage No. of Water Heaters KW S' s Bailases wiring No. Hydro Massage Tuds tors Total HP OTHER: T/L�// '" V6"� � —h1V5 INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) l– `� (Expiration Date) Estimated Value of Electrical Work$ Work to Start 1--'g_ iY Inspection Date Resquested r/Ir'`7F Rough Final Signed under the PerVgles of perjury: dcyt, LIC. NO. l G FIRM NAME /�/�f/1/� �C'7,�1G4C2 ����—,,q NO. Bus"Tel No.Z- Address C� �7'``/b ✓/ 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) Fcatn 1� No. Date r TOWN OF NORTH ANDOVER op Certificate of Occupancy $ } ;* Building/Frame Permit. Fee $ Foundation Permit. Fee $ s�cMusE Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ DIN 12348 05/14/98 13.422 Building Inspector 58.00 PAID Div. Public Works ocatlon No. F Date TOWN OF NORTH ANDOVER o? ' F n Certificate of Occupancy $ Building/Frame Permit Fee $ NUSE Foundation Permit Fee $ S,u x. Other Permit Fee $ ' Sewer Connection Fee $ x. Water Connection Fee $ TOTAL $ Building Inspector 4 : , 114f93 13:41 5&00 PRID Div. Public Works en d 3 W V x u LJ F 1 z z Q c m � N o O Z z A 5 N CAm 7 E.n W K k* \� J Zz A J C N C C w 61 3 � m Lu V) LLJ mV) a � cn O cn rn rn C 7 C7 W 2 } v LU $Lu z Q to L r1I z m m L, C r` C y y VI to G F� O z o � � Q U �• o G G - r.` W Q W z � r ? � l/� �a Z LLI z N>Z L N E N E :n _ m on'] z z i Lu O � z Nw J w F LLI 0 E., z z � Z � ;n Ln J ^ Z r W w C - LLI 3 W V x LLI LJ F z z Q c m m a Z z 5 N CAm v rn W =V.1 a V) - qo ON W tqll EM a a a o w cm z w° x X U a w x w x� w � w cc cn o cn tqll EM Location / / ���'��©w �AA,)L No. .J- Date /a .s TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ __ • , "I',,b'•••• •''��' SSACMUSE Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL A /Y41. 12928 12/21/9811:08 j Building Inspector 25.00 Div. Public Works M©i Q Z c � �* 3 W L C. N u c Z 1 C N u z z � 'h O G 1 Q Prl W • t Q � "r N V � CL rr �_ �^ C: v u• � LU y t 3 7 J C Z O 3c -K LU W � Z ;r. We O � Y N Y H y N W c } W C G W V Z o G Y i y 1 Z Z LL• Z Z y_ O 9 rr ry - n - •✓l 2 :n r+ N L 0 Q �n LLJ N U N 1y \ a 7 ; y x _ ' zLUcr 7 z' tY y �' z Z Z C Q' - Z n � W J W Z C Z C C CO.' z :J - --u u r 9 W in z W ::J Z c L �* 3 W L C. c Z u z } 'h V 1 Q Prl W • t J N V � CL CL �^ C: v u• � LU y t 3 7 J ^ Z L W C. Z u Z 'h V � z LU a 3 7 J V, w O m C v u p O w a v cn Cd O U z O z a C g O w O a' v -C U is C w OO U C7 a °�° O C W w W nCo O vi C r=. p a nan O raw ro C w H W w a W w C 7 as z V)C/) o x O ui U) O E N IU 6 .S� 6 O s v CD O E CD O v Z o Q. O y D C CD I Com_ V� a 'O O M E m m CD CD CL ~_ CD ♦- 3 -o 0 0 0 cc o a y C *-0 C C cc ca C z CD U CO) cc C . C cc H 0 � o CD c r- 0 C N O C r.+ O V V �d O. Cm O O CO :L G +-' � • O D N � m H o` D • : o, c C CLca N o N Cm C m .m CD �► o,C.3 . .n c oa Q,cz 0 y O C. HQ y m C m= 3 E... m h W r0.. =y0.. .y=...'fl Z OC - ra c +- me O C CAA dt COD 06 m� O� s H o .c 0 $ a w m U) O E N IU 6 .S� 6 O s v CD O E CD O v Z o Q. O y D C CD I Com_ V� a 'O O M E m m CD CD CL ~_ CD ♦- 3 -o 0 0 0 cc o a y C *-0 C C cc ca C z CD U CO) cc C . C cc H 0 � I N° 2 1 7 7 "a TOWN OF NORTH ANDOVER ��.!�L p PERMIT FOR WIRING This certifies that.........Qq J (_1 ccf a ( L .......................... .................. G _ has permission to perform t �1. moi. .... S (- „/ �,� 4 wiring in the building of ... �.%.. Q ,T T'1 ....................................................... I q /.. It ....... f 3..... %i� � o „Gf ��....L". �..................... .North Andover, Mass. Lic. No...T.,!.�J........................................................... (� ELECTRICAL MpEcm %1/98 41 c 34.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THE00MM0NWE4L7H0FAf4MCHLSE77S Office Use DEPARTMENTOFPUBLICSAFM Permit No. BOARD OFFIREPREVEM70NREGUMT10ASR7CW 12:00 ' Occupancy &Fees Checked APPUCATIONFOR PERMT TO XWORVIELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527"CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ill Town of North Andover J To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) qel gj 2O�u Owner or Tenant cS�:qwE i T % Owner's Address S4,M e- Is this permit in conjunction with a building permit: Yes © o (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Underground M No. of Meters New Service �._ Amps / Volts Overhead Underground =1 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Rot Tubs No. of Transformers Total KVA of Lighting Fixtures Swimming Pool Above Below Generators KVA t)No. ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local® Municipal Other No. of Dryers Heating Devices KW _I Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER. A1112, Z 6;1< FRe-70w ee- �tiSc�722T� I Irs==Ca� Rx9mtlDthete puTntisofTvwmdisMGanalLaws IhaeammlLnU*h ua=PbbcyiddTCaWkt ' CoAmWoritsabAmtiale4.uvaiaE YES a NO Iha%eabnttedNeWpfOdOfsametpthe0� YES M NO a If}whmedtadwdYES, pkmmdicalethet}pecfwmagebydxdcrtgthe WSURANCE BOND r7 OIIHER Q (P{ mSpa*) Expitzdw D* dc�Stat �%`- % ES Vahre iralWak$ Wo Irspadia►I�Rawe0d Rough FM sigmdurdAlambies FIRM NAME �� C�LE� /%�i� Lit�aseNa �/ .�y t' licalsee ��� "LL1ZL�l ISignaffe 111al"z6/�_— L ilseNo BtsisTel.No, 6 2– Aw,ss AIL Td NcL OWNER'SINSURANCEWAVER;Iama%kmdatftLioe duesio eitstrareco�aa@ea le ela#astec�madbyTviassadxset��Iaws andfirtmysgutseuntNspmnitappficadmwai.cst iste�m-ot (Please check one) Owner ® Agent M Telephone No. PERMIT FEE $ ' c�t *3 zi: MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 'ype or print) NORTH ANDOVER, MASSACHUSETTS f Building Locations �1 % mil •P= d w Q. �✓ Date a 2L / � Permit # 120 C Amount Owner's Name New Renovation j� Replacement Plans Submitted •�'. FIXTURES (Print or type)� // n Check one: Installing Company Name P jf 7 if -t -a Corp. Address S -Z) no K I ',,a /2- -�y' Partner Business Telephone („ � 6- h q, '2- J Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity 11 Bond ❑ Certificate 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 Signature Owner n Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass ac s Sta PlumbiP Code andoapte5,,K of the General Laws. By: Signature of Licensecl Flumner Type of Plumbing License Title City/Town kens um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY • - • (Print or type)� // n Check one: Installing Company Name P jf 7 if -t -a Corp. Address S -Z) no K I ',,a /2- -�y' Partner Business Telephone („ � 6- h q, '2- J Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity 11 Bond ❑ Certificate 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 Signature Owner n Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass ac s Sta PlumbiP Code andoapte5,,K of the General Laws. By: Signature of Licensecl Flumner Type of Plumbing License Title City/Town kens um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY .0. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Cype or print) NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New 13 Renovation 1:1 Replacement 0 FIXTURES Plans Submitted n Date Permit # Amount (Print or type) Check one: Certificate Installing Company Name n Corp. Address n Partner. Business Telephone El Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 11 Other type of indemnity 11 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 Signature Owner 11 Agent n I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate.to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By: IgnatUre Ot LicenseclPlumber Type of Plumbing License Title City/Town License Number Master Journeyman ❑ APPROVED (OFFICE USE ONLY \ ov Jt � Date y 3706 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...J?.•.. �9.1��?.�;?47................ has permission to perform- .5X c,. L -f— :,�0 .............. . plumbing in the buildings of ........... at. ..�'�.� .... North Andover, Mass. Fee..a. PLUMBINGNG I CT 45/22/98 08:39 25.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer (0.- ; ,.a Date . L 2 ..... J........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . �...z... . !!....... ... ......../ ......... .................................... has permission to perform ...... .............................................. wiring in the building of..!a.C?..C?.'...!...................................................... at ....5:2..a...... .................... . North Andover, Mass. Fee.. }.:..:....... Lic. No ............... ............................................................... ELEcrRicAL INsncroR Check # -23 1/ez 4414 Convnonwea� a`cc///allacliuu�J 1JrPar�ni o`.}ir'i sinricee BOARD OF FIRE PREVENTION REGULATIONS For Office 7 -711 - (Rev. 11199) Permit Number: Occupancy & Fee APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:00) PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: !/y1�/�� zoco City or Town of: & ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his order intention} to perform ;he electrical work described below. Location: (Street & q' Owner or Tenant: "'e/46+ $aoin /y'la1m-g Owner's Address: Is this permit in conjunction with a Building Permit? Yes o No b-,' (Check Appropriate Box) Purpose of Building: S( ►"Li ),F Utility Authorization #: Existing Service: 0') Amps 6Z4) / '%Volts Overhead Underground.❑ #of Meters New Service: 2D b Amps l 20 / Volts Overhead Underground.❑ # of Meters: Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work:_ No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Transformers Total KVA No. Of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool: Above ground ❑ In Ground ❑ # of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners Fire Alarms # of Zones # of Detection & Initiating Devices # of Sounding Devices: # of Self Contained a Detection/Sounding Devices Local o Municipal Connection o Other ❑ No. of Switches No. of Gas Burners No. of Ranges I No. of Air Conditioners TOTAL TONS: No. of Waste Disposals Heat Pump Totals: Number: TONS: KW: Security Systems: No. of Devices or Equivalent No. of Dishwashers Space /Area Heating: KW Data Wiring, No. of Devices or Equivalent: No. of Dryers Heating Appliances KW Telecommunications Wiring: No of Devices or Equivalent: No. of Water Heaters KW No. of Signs: # of Ballasts: OTHER; # of Hydro Massage Tubs No. of Motors Total HP 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 fo`rcce,, and^hlas� exhibi o pproof Toff same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER 13 Please specify: VCS 1��'�r'C\ Estimated Value of Electrical Work (When required by municipal policy) I Work to Start: 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. d Firm Name: !✓/7 L LiC //C GO -A C- LIC. # �/ 33 Licensee: S � "/ Jam, Signature: LIC. # �� '3 3 /i C (if applicable, enter " empt" In the I�nse num4 r line) Address: 5� % (_ wlc EnIma /� r� ///�,�7�Y�Od/�.E'f �fq O/�yJ/Bus. Tel. # kdG 3- Alt. Tel. # 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 a OR Agent ❑ Signature of Owner/Agent: Telephone # PERMIT FEE: S