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HomeMy WebLinkAboutMiscellaneous - 59 Maple Avenue 59 rlaplE /1ve BUILDING FILE l �9 Maple Ave, Date......(.. .... S TOWN OF NORTH ANDOVER .0 PERMIT 'FSR WIRING S. CHU This certifies that ...... ............... ............... ...... has permission to perform ........... ..................................... wiring in the building of......... . ......................................N pjh Andover,Mass. Fee..................... Lic.No..]../,. ..... ... .. ...... ELECT ICAL INSPECTOR Check # 10403 N Common-wealth of Massachusetts Official Use Only Department of Fire Services Permit No. / d Occupancy and Fee Checked RD OF FIRE PREVENTION REGULATIONS Rev. 1/07 BOA � 1 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 1� aS /I City or Town of: NORTH ANDOVER To the 1`nspector of Wires: By this application the undersigned gives notice of his or her intention to perfnr&tVelectrical work described below. Location(Street&Number) 4'57 Owner or Tenant A" Y*P L G'i � M10� ✓``� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (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: L ,PMC,'^� , � ' 1.N 4CQ�--� Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SNo.of Total_usp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ NO.o Emergency Lighting nd. rnd. Battery Units -—. No.of Receptacle Outlets No.of Oil Burners FI E ALARMS No.of Zones No.of Switches No.of Gas Burners NO..of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tootal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: ........... Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local[IConnection ❑ Other No.of D ers Heating Appliances KW Security Systems:* DryNo.of Devices or Equivalent .� No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts. No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:� 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE;F� BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of peri ,th t the information on this application is true and complete. FIRM NAME: -S �l b �G#ak C LIC.NO.: Licensee:te r-- y Signature LIC.NO.: (If applicable,enter"exempt"in the license nuinber line.) Bus.Tel.No.: Address: �� Alt.Tel.No.: 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 agent. Owner/Agent PERMIT FEE.$ Q.—+.— Telenhnnr Nn- l The Commonwealth of Massachusetts w. ! Department of Industrial Accidents •-,• Office of Investigations i,l,l; 600 Washington Street Boston, MA 02111 { , www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nannie(Business/organization/Individual): Address: City/State/Zip: Phone#: . Are you an employer?Cheek.the appropriate box: ' Type of prgject(required): 1.❑ 1, aro a employer with 4, ❑ 1 am a general contractor and I employees(full and/or part-time). have hired the sub-contractors b ❑New construction 4 2.❑ I am.a.sole proprietor.or partner- listed on the attached sheet.1 7. ❑Remodeling ship and.have no employees These sub-contractors have 8. Q Demolition P working for main any capacity, workers' comp.insurance. 9, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporafion and its required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ I din a homeowner doing all work right of exemption per MGL I I n Plumbing repairs or additions myself, [No-workers'comp. c. 1.52, §1(4),'and we have no 12.[] Roof repairs insurance-required.]t .employees. [No workers' comp. insurance required.] 13•❑_Other °Any applicant that checks boa'#t must also fill out the section below showing their workers'bompensation poiiey information. t Homeowners who submit this affidavit Indicating they are doing all work and(lien hire outside contractors must submit anew affidavit indicating such. -_ 4Conlractors that check this box mrzstattached an additional sheet showing Lite name of the sub-contractors and their workers'comp.poli^;infarr ialloa. I am an ewployer that es providing:tvorltepa'compensa&a imsuranre for my information efttpinyees: Belowis the policy ared job site Insurance Company Name, ' Policy#or Self-ins.Lie.#: Expiration Date: ^� Job Site Address: City/State/Zip- 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- fiine 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 certify under the pains and penalties of perjury drat the information provided above is true acrd correct, Sienature: Date: Phone#: Wlciat use only. Do not w.rhe b2 skis ser ea,to be completed by city or town.ofjiciaL City or Town: Permit/License# 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#: 0 0 -57 MAPLE A VENUE 019.0-0036 Complaint Detail Report Printed On:Thu Aug 29,2013 Complaint#: CT-2014-000009 Status: lClosed GIS#: 711 Violator: Address: -57 MAPLE AVENUE Map: 019.0 Address: Date Recvd.: Jul-25-2013 ITime Recvd.: 04:00 PM Block: 0036 Category: Housing Lot: Type: GeoTMS Modules Board of Health District: Trade: Recorded By: jLisa Blackburn Zoning: Structure: Description Complaint: Written complaint made by Emmanuel Figueroa regarding mold,bugs,squirrels at 59 Maple Ave.See attached letter.Forwarded to Michele Grant,Health Inspector. Comments Inspector Assigned to Complaint: Michele Grant Contacts Contact Type Date Time Name Phone Best Time To Reach Recorded By Response Tenant Jul-25-2013 4:00 PM Emmauel Figuerroa (978)621-8557 Q Lisa Blackburn Follow-Up by Health Inspector Actions Taken GeoTMS Module Status Date Time Response Type Action Taken Comments Board of Health REFERRAL Aug-29-2013 2:36 PM Follow-Up by Michele Grant contacted the Michele Grant new owners of the building. They will be doing a walk through of the apartment. Mr.Figueroa was told to give the new owners a chance to see what needs to be fixed and if the new owners did not complete the problems to call the Health Department back.Case closed. GeoTMS®2013 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 rtORTly ���t`Ep 6'4/rO Y 3? 0 • 4. 6 OL F- A T O COtwt H,M.K.1 V� �.4 A0q•Ti0 SSAC HUSH PUBLIC HEALTH DEPARTMENT Community Development Division Letter of Comuliance DATE: July 26, 2007 TO OWNER OF RECORD PROPERTY LOCATION Sylvia Schofield 59 Maple Ave. 11 Mill Ave. North Andover, MA 01845 Manchester, MA 01944 A Health Department RDER LETTER dated April 26, 20 06 was issued to you as owner of record of the property listed above citing violations of the State Sanitary Code, 105 CMR 410.000,Minimum Standards of Fitness for Human Habitation. In addition to a re-inspection of the property on July 25, 2007 a letter has been submitted to the Health Department, by the North Andover Building Department,indicating that all of the violations noted on the Order Letter have been corrected. Sincerel S Y. Sawyer S/RS Public Health Director Xc: File Andover Building Dept. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com ORTH 'CO or I he ion Rd ing Deparhmemt anal Service, July 26, 2007 59 Maple Ave. North Andovo' MA Ol 845 Thc work covinpletcd,at 59 Mapic,Avg,Ruects hc Minimmi-n rquirmouts ruguested 1)),the,bealth and. Mailing date : July 17, 2006 pl Jul- S 5 20a� ANDOVER �p`NN OTH DEPP T��ENj HEA I I Michele Grant, Inspector N. Andover Health Dept . 400 Osgood Street North Andover, MA 01845 it Northeast Housing Court 2 Appleton Street Lawrence, Massachusetts 01840 (978) 689-7833 Susan M. Trippi David D. Kerman Clerk Magistrate Associate Justice Date : July 14 , 2006 RECEIVED Re : N. Andover Health Dept . Vs : Sylvia Schofield JUL 2 5 2006 No : 06-PC-00281 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT NOTICE OF SHOW CAUSE HEARING A request for criminal complaint naming you as the defendant has .been filed in this Court, and a copy of the proposed complaint is enclosed. Before any criminal process issues, the Clerk of the Court will hold a show cause hearing to determine if there is sufficient evidence to require that you be charged with the offense alleged. A clerk' s hearing to determine whether criminal proceedings will be commenced against you will be held at the Clerk' s Office of the Northeast Housing Court, at 2 Appleton Street, Lawrence, MA 01840 at 02 : 30 o' clock, Monday, July 31, 2006 . At the hearing you may present your side of the matter, bring witnesses, and be represented by an attorney, if you so choose. Sus r' p Clerk Magistrate ECMS : SCH-SCAUSE REQUEST FOR CRIMINAL COMPLAINT FOR STATE SANITARY CODE VIOLATIONS To any Justice or Clerk-Magistrate of the&V� Housing Court on behalf of the Commonwealth, on oath complains that: was and is the owner of residen ial premises located at , On h1ort C) � 200 C, a representative of the - __ �v -- - ---------------- ------Program inspected the said premises nd determined that the dwelling did not comply with the provisions of Article II of the State Sanitary Code, 105 .M.R. , §410. 000; On 200 , pursuant to §410 . 832 - 833 of the Codb, the defendant was served with a written order to compl On U� 200 . , and from day to day thereafter the defendant has failed to c�Omply with the order, each such day being a separate offense and a separate and distinct count of this Complaint; all in violation of State Sanitary Code, 105 C.M.R. , §410.910-920, and the public health law, Gen.L. c. 111, §127A, and the defendant did so willfully, intentionally, recklessly or repeatedly. ("o D e: Complainant. Assigned for hearing on , 200 !P, at O' clock. �— On -hearing (Complainant) (Defendant) (both parties) (neither party) , I find no probable cause for the Complaint. Process shall not issue. On hearing (Complainant) (Defendant) (both parties) (neither party) , and Complainant having sworn or affirmed that the Complaint is true upon information and belief, I find probable cause, and order summons to issue returnable IVED A A 4ate* Clerk-Magistrate JUL 2 5 2006 TOWN OF NORTH ANI.OVER HEALTH DEPARTMENT NORTHEAST HOUSING COURT FENTON JUDICIAL CENTER 2 Appletgn Street L Lawrence MA 01840 AUf"36 a. . fN p, H METER 5f 4? ; N0IFY SENDER OF NEW ADDRESS HEALTH DEPARTMENT 1600 OSIaOOD ST STE 284 NORTH. tANDOVER MSA 0 1045-1 OSO MC: 01045105064 *3021-00376-10-41 50%RECV®PAPER a�01 I'Ao 1)111iJ11I1IM11)I t l'l 111l 1l')i1'h!)l I)MI)IJIlh1' 30%POST-CONSUMER - I 59 A ❖ Check or n #7 L C� out dwelling) 1. Fixtures wit _ 2. Fixtures -n( � i A in wooden frame) 3. Fixtures—c equired for mounting ❖ Electrical selling) 1. Check for: 2. Check for: proper wiring &polarity (with tester, i iuund some problems) 3. Correct wire sizes? —Kitchen/dining/bath rooms 4. GFCI* outlets—bath—kitchen (not working)- need additional in some areas 5. Smoke & Co detectors 6. Baths need: fan vents_ducted outside 7. Electric bath tub 3`d floor—no GFCI* protection? 8. 3` floor tub and sink areas—no GFCI* protection? ❖ Basement 1. Hanging wire or cable(staple) 2. Rear room rewire and install GFCI* outlet protection (damp location) 3. Cable - romex type - stapled across ceiling joists (needs running board) 4. CATV wire entering from outside through dryer vent piping? 5. Box covers,boiler room area missing, wires need stapling 6. Main electric panel area: Need GFCI* outlet protection j * GFCI={GROUND FAULT CIRCUIT INTERUPTER} PER: 2005 National Electric Code Massachusetts Electrical Code-527 CMR 12.00 Massachusetts Department of Public Health - 105 CMR—Sanitary Code ➢ MOST NEEDED: 0UALIFIED ELECTRICAL CONTRACTOR Peter Murphy North Andover Electrical Inspector 59 MAPLE AVE. NORTHANDOVER,MA. ❖ Check or repair electrical lighting fixtures (Through -out dwelling) 1. Fixtures with out electrical boxes 2. Fixtures - not readily accessible to boxes or wires (encased in wooden frame) 3. Fixtures_ceiling fans all floors_special fan boxes are required for mounting ❖ Electrical Outlets/other devices (Through -out dwelling) 1. Check for: electrical boxes on outlets & switches 2. Check for: proper wiring&polarity (with tester, I found some problems) 3. Correct wire sizes? —Kitchen/dining/bath rooms 4. GFCI* outlets—bath—kitchen (not working)- need additional in some areas 5. Smoke & Co detectors 6. Baths need: fan vents_ducted outside 7. Electric bath tub 3rd floor—no GFCI* protection? 8. 3d floor tub and sink areas—no GFCI* protection? ❖ Basement 1. Hanging wire or cable (staple) 2. Rear room rewire and install GFCI* outlet protection (damp location) 3. Cable - romex type- stapled across ceiling joists (needs running board) 4. CATV wire entering from outside through dryer vent piping? 5. Box covers, boiler room area missing, wires need stapling 6. Main electric panel area: Need GFCI* outlet protection * GFCI={GROUND FAULT CIRCUIT INTERUPTER} PER: 2005 National Electric Code Massachusetts Electrical Code-527 CMR 12.00 Massachusetts Department of Public Health - 105 CMR—Sanitary Code ➢ MOST NEEDED: OUALIFIED ELECTRICAL CONTRACTOR Peter Murphy North Andover Electrical Inspector Date. . . E HORTM TOWN OF NORTH A VER • PERMIT FOR AS I TALLATION -�• . D �9SSACMUbE This certifies that . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . !f . . . . . . . . . . . . . . . . . w in the buildings of . . . C. .�'. . . . . . . . . . . . . . . . . . . . . . at . . . . .4 ��. !'?.�'''�' . . . . . . . . . . . , North Andover, Mass. Fee. . .. . Lic. No.I 1-e.C GAS INSPECTOR Check# r) L 581 _ _ l M%ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) t NORTH ANDOVER Mass. Date Euilding Location _Tq yyj� Sf, Permit r Owners Name New '-1 Renovation Replacement Plans Submitted D FIX? 710 � W G1 � e t. a y. z o t- cc d m to tW- 0 0 = a X tw-- w 14 tt: N O w 0 N t1. !r > 4 N Q w Z V = I= Cf 4 = O q m O us F- z I" J H z �., W w a d > LL t- U .1 fw- ttuu LLIW d ,Lr > C W d G 4 = =10 is U. c� 0 -4 v � > a 00. 1.- o SU$—RSldT. i 4 BASEMENT V1I tSTFLOOR a 2ND FLOOR 3130 FLOOR I 4TH FLOOR STH FLOOR 6TH FLOOR TTH FLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name F Q Corp. Address Partner. p ��Fi rm/Co. 'k Business Telephone: - Name of Licensed Plumber or Gas Fitter 1 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �er type of indemnity Q 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 coverages. Signature of owner/agent of property Owner 17 Agent F7 I hereby certify that all of the detains and information I have submitted (or entered)in above application are true and accurate to the best of my knowtedge and that all plumbing worst and installations petformcd under Permit issced for this application will-be in compliance with ad pestlaent provisions of tho Massachusetts State Cas Code and CQuptes 14:of tho General I.Aws. By P ELICENSE: r er Title tter ignatur o Li ensed City/Town: Plumber or Gasfitter APPROVED (OFFICE USE ONLY) eyman License Number Date./%/?. .<. . . RT" TOWN OF NORTH ANDOVER ► PERMIT FOR PLUMBING z ,SSACMUS� ' f This certifies that . . . �//.�f . . �.�. . j. . �. VC . has permission to perform . . . . -.t.- . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . at . . . .�: , . E.�� �. . . . . . North Andover, Mass. . Fee. Lic. No../��a.��. . . . . . . . . . . . .1.,. -7 PLUMBING INSPECTOR - Check # /z 188 s MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (please tgpe or print) _ o ► ovr�r- Mass Date: _& a-2-4 � �- L T +��'�. }t "n-�i v��V'a�rr;.. �`Z� •- a •,_ � �,�',syr rf �t�,. .�w d o � � �1i '.:r T v �"� i.. �°S.+ � ,'"' x E { s k.ay 'S# �"�1�4: h`N}�ay�.i,���a,.�,�p -�-. i rr� .i ::.• �� ' ��,.r+� � 9� k � r tyrt .�,, «¢ e,., •is � 'x"°ti ., '�,;rwc�� ��i:.� 'i x i,.,•� Y ,.9,�,i,"`',C`.?�^ >c'hyNY�'4 � k -:,ilk�e a!�'r' .�' S �^A�"'h*q- :!?" 4� .� �..z , r t�. .4*,`;y i r.,i} y.Rf:..:.. �. �(il�+,. �� ut.y�. "'"S' "+ .t�° 5.,: V-1" Y'•^ T b „�e! ` rS`hf�..y^� �.6tie�ap; ( i ` iNr ��,r ��,�'rl Dwner New ❑ Renovation ❑ Replacement Plans Submitted ❑ FIXTURES z �, z Z z Q it a = ~ Z a rnLuw F- U GC CnZ O Z Z O z O it Q W c}C 2 B 0 Z 2 Q y cr a 2 O LL LU o ac w w z N w = Q 2 O 2 d CrF- Q be 0 U, jr LL W Q^ > 1- O 3: TO Q !-- Z O O In Z Z w < O O U S �S �G .a.1 0a0 ai 0. 0 J s s° )Q- t i �° Cr- Q i m o * SUB-BSM T. y BASEMENT y' 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name: Please Check One: Certificate Address: ❑ Corp. ❑ Partner. Business Telephone: - [�irm/Co. Name of Licensed Plumber: Z27 e`i a ed j: _ r , Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability Insurance Policy 1� Other Type of Indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the license of this application does not have any one of the above three insurance coverages. Signature of OwnerlAgent of Property Owner ❑ Agent F#ta Oy�cwifl'y that d of the details and Information 1 haw submitted for entered)in above applieatkm are true and accurate to the beat of my knowledge and that all plumbing work irl#1:'�'Ata iNlilthi[fll= Wormed under Permit issued for this application w ll be in compliance with ag pefthmnt provision of the Massachusetts State Plumbing Code,Chapter 142 of the • 0MCE USE ONLY) Signator of eased lumber- iiyao n; Type of Plumbing License:. Master�urne�►man Date ................................ I NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING S CHU This certifies that ............. P"0.9 le.................................. has permission to perform ..... ....... ......... wiring in the building of...... ........;5r4l ............... at......V.,5 . .................. .North Andover,Mass. Fee..-R5. Lic.No.yi! 74- .Y.6............... ELECTRICAL INSPECTOR Check # 4` 6979 1 Official use only Commonwealth of Massachusetts Department of Fire Services Permit No. 6171 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: c-P, 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) 4-19 Au- Owner or Tenant S11y1A A,, I 'a Telephone No.��• ��,•/7S2 Owner's Address Is this permit in conjunction with a building permit? Yes Pool, No ❑ (Check Appropriate Box) Purpose of BuildingUtility 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: UP944 N,: SoyuL- Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.ot Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El No.o Emergency Lighting rnd. rnd. Batter 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: No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Numberons IKW 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 Systems: No.of Devices or Equivalent No.o Water KW No.o No. o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: No.of Devices or Equivalent OTHERjOhAlge- �� Sit P ' Z Attach dditional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work:, (When required by municipal policy.) Work to Start: dw 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 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 ins and pe,allies of perjury,that the information on this lication is true and complete. FIRM NAME: 4 WV 66 ZIEW LIC. NO.: X1)21 - Licensee: t J (ftSignatu e .` LIC. NO.: tf D 7f ZE (lfapplicable, enter, "exempt"in the license number line) Bus.Tel. No.:��f41-307'�yd'7 Address: Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: 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. FPERMIT FEE. $ i 1 � l MW At -7e9 �P i i wc/ 4c"V 2