400 HIGHLAND AVENUE, S204- B-12-691 I The Commonwealth of Massachusetts
U Department of Public Safety
I I Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
�00 ► ri+h +,dPa(R [q aje1A 01R`70 hWh la,,nd
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK '^
a;t Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below
-34�Existing Building❑ Repair❑ Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review required? J Yes ❑ No
Brief Description of Proposed Work- �Ph/OQ �/YYtc[1 hp— `Yi'1f'_ Qbt-/S77 h 5t
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
- -' CHANGE IN USE OR OCCUPANCY
Check here if an Existing ding Investigation and Evaluation is enclosed(See 780 CMR 34) ❑'
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ( )
Total Area(sq.ft.)and Total Height(ft.) 30(p l s4a f.
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B. Business . E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
.., ,. .. SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 13 IB ❑ IIA ❑ IIB IIIA ❑ IIIB ❑ IV ❑ VA O VB O
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
i Permit., Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Dis osal Site
Publicw Check if outside Flood Zone❑ Indicate municipal)( french will not p
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-o -w T Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or Noy Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: " Special Stipulations:
' SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pro ty Owner
"Nam,(
hind u(k �s Igo ��a Vnk9' �arhj?�2af��1� hi K
Name( int) Ij No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
�ine,�- '�aYtLn rs gojSP,2lrrc+r ,�i11�tNA -E jvsl j�A (p3�2
Name Street Address City/Town State Zip
to act on the ro er owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 17 and skiE Sectionf 10.1.y
10.1 Registered Professional Responsible for Construction Control '
Name(Registrant `Te1lephone No. e-mail ad 3 R astration Number
�aoDll re �+ Sr .L4tAIS (o lol iC
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Fmc, S � min �e r5
Company Name
Name of Peprs�on Responsible for Construction License No. and Type if Applicable
qL �,I�tI�M���I 4U� I c N Cesa-C ,<,k r �A Ir 0-
Street Address City/Town State Zip
6(0 _q�_ 3333 KMRck�Nzi��PINES+s eel C�rDen�e.rs ,cem
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'CONWENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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
Is a signed Affidavit submitted with this application? Yes 13 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$ rb
1.Building $ Building Permit Fee=Total Construction Cost x I (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to Li'hl/ 07 _ i8
6.Total Cost $ (contact municipality)and write ch ck number here
SE ON f 3:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and underslanding.
�1@,khMarkrnzlP. Alf (0l�_ 3333 iY
P ase prt�,tn¢si ramg- e Q Tele 17on o. ate
D I J 15!)IMRS� l 7U1 /J f a ( 2
Street Address City/T wn State Zip
Municipal Inspector to fill out this section upon application approva 1 /
Name Date
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark'Y'where applicable
No. Item Subipitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to Mple the original permit
fee.
Registered Professional Contact Information
AY o(L k GG d q02-3°II --1foa
Nam (Re strant) Telephone No. e-mail address Registration Number
�,
30X �1�a_Y- �:,6 NE /
Z �
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
-12001 ye + S4-.Lou LS MO 31p/
Street Address City/Town State ZipDiscipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip IDiscipline Expiration Date
l
CITY OF Siuy-m 1rL SSACHUSETTS
BuI DNGDEPkRTNE&NT
120 WASHIINGTON STREET, 3" FLOOR
T EL (978) 745-9595
FA.K(978) 740-9846
KIJIBERLEY DRISCOLL
,AMAYOR THob LA s ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CONC-aSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
I11
Mt-t/ � MY
(name of hauler)
The debris will be disposed of in :
(name of cility)
&CM11 t l V�
(address of facility)
4sirnmatdurcofperm�it
date
dcbrisuff.Joc
i CITY OF S�Uxam, NWSACHUSETTS
• BUILDING DEP:IRT'RfENT
120 WASHINGTON STREET, 3"FLOOR
TEL (978) 745-9595
E e(978) 740-9846
KI\IBERL.EY DRISCOLL
MAYOR THolius ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUIIDING CO\WISSIONER
CONSTRUCTION CONTROL DOCUMENT
Project Title: Date; 31 2
Project Location: O
Scope of Project:
In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code:
Mass.Registration Number ' _ds�
being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
[ J Entire Project Architectural [ ) Structural [ ] Mechanical
[ J Fire Protection [ Electrical [ ] Other(specify)
for the above named project and that to the best of my knowledge,such plans,computations and specifications meet
the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore,I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit,and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials,
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general,if the work is being performed in
a manner consistent with the construction documents .,;
6 '
I shall submit periodically, in a form acceptable t iltng progress report together with pertinent
comments. Upon completion of the work,I shal t to the bui g ficial a final report as to the
satisfactory completion and readiness of the proj f r occupatgg(y
o
` 9ALIANA
Signature and Seat of registered professional;
0e
The Commonwealth of Massachusetts + `PrintForm
Department oflndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Pine Street Carpenters, Inc.
Address: 901 S Bolmar Street, Suite N
City/State/Zip: West Chester, PA 19382 Phone #: 610-430-3333
Are you an employer? Check the appropriate box: Type of project(required):
LE I am a employer with 35 4. ❑ I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6. El New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. ❑ Building addition
requi red.1 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
"My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors 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 most provide their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Cincinnati Insurance Company
Policy#or Self-ins. Lic.#: WC1923392 Expiration Date: 6/28/2012
Job Site Address: 400 Highland Place City/State/Zip:Salem, MA 01970
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
fine 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 cEEq&under the eains and enalties o er'u that the in ormation provided above is true and correct.
Sienature: -- Date 1/25/2012
Phone#: 610-430-3333 ext 116
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
OP ID:AG
CERTIFICATE OF LIABILITY INSURANCE DAT06122D/1
O6/22/11
THIS CERTIFICATE IS ISSUED AS A 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
BELOW, 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(les) 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 certificate does not confer rights to the
certificate holder in lieu of such endorsements.
PRODUCER 610-279.8550 CONTACT
The Addis Group,Inc. 610-279.8543 NAME: FA
2500 Renaissance Blvd.Ste 100 Arc No .t: a No:
King of Prussia PA 19406.2772 E-MAIL
Joseph T.Merc(Tant ADDRESS:
MMMIROTINIES-11
INSUR S AFFORDING COVERAGE NAIC Y
INSURED Pine Street Carpenters,Inc. INSURERA:Cincinnati Insurance Company _ 10677
901 S.Belmar Street,Suite N INSURER a:
West Chester,PA 19380 INSURER C:
MSURER D
INSURER E:
INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE PO OF POLICY EXP
LTR POLICY NUMBER fM IMMUDINYYYY) LIMITS
GENERAL LIABILITY
EACH OCCUR FRCE $ 1,000,00
A X COMMERCIAL GENERAL LIABILITY CPP1068725 06/28/11 06/28112 $ 600,00
CLAIMS-MADE XOOCCUR MED EXP(Anyone person) $ 10,000.
PERSONAL$ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 3,000,00
GEM%AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AEG $ 3,000,00
POLICY X PRO- LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ee accident) $ 1,000,00
A X ANY AUTO CPPI068725 06/28/11 08128/12 BODILY INJURY(Pet poison) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
SCHEDULEDAUTOS PROPERTY DAMAGE
X HIREDAUTOS (Perace at) $
X NON-OWMFDAUTOS $
X Comp$250 $
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION X WC STA7U- OTH-
AND EMPLOYER$'LIABNTY
A ANY PROPRIETORIPARTNERIEXECUTIVE YIN C1923392 06/28/11 06128/12 E.L.EACH ACCIDENT $ 500,00
OFFICERIMEMBER EXCLUDED? NIA
(Mandatoryin NH) E.L DISEASE-FA F1dPLOYEE $ 600,0
Iryyaes describeorder
OESLARIPTION OF OPERATIONS below ELDISEASE-POUCYUMIT i SOO,OO
OCC
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarlus Schedule,If mom space is required)
CERTIFICATE HOLDER CANCELLATION
COMMONM
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
The Commonwealth of MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Department of Industrial Acctd ACCORDANCE WITH THE POLICY PROVISIONS.
Accidents
600 Washington Street AUTHORIZED REPRESENTATIVE
Boston,MA 02111 649 T. )1zla.
01988.2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
COMcheck Software Version 3.8.1
Interior Lighting Compliance
Certificate
2009 IECC
Section 1: Project Information
Project Type:Addition
Project Title :Weight Watchers
Construction Site: Owner/Agent: Designer/Contractor:
400 Highlands Place Gregory R.Schnackel P.E.
Salem,MA 01970 Schnackel Engineers,Inc.
Omaha,NE 68124
402.391.7680
Section 2: Interior Lighting and Power Calculation
A B C D
Area Category Floor Area Allowed Allowed Watts
(ft2) Watts/ft2 (B x C)
Retail 2334 1.5 3501
Allowance:Other retail highlighting/Fix. ID:Track 500(a) 0.6 300(b)
Supplemental Allowed Watts(c)= 540
Total Allowed Watts= 4341
(a)Area claimed must not exceed the illuminated area permitted for this allowance type.
(b) Allowance is(B x C)or the actual wattage of the fixtures given in Section 2,whichever is less.
(c) Supplemental watts must be associated with retail merchandise highlighting fixtures.Supplemental watts are not included
calculation of lighting complaince percentage.
Section 3: Interior Lighting Fixture Schedule
A B C D E
Fixture ID:Description/Lamp/Wattage Per Lamp/Ballast Lamps/ #of Fixture (C X D)
Fixture Fixtures Watt.
Retail(2334 sq ft.) " -
Incandescent:3:Mono-point Head/Incandescent 75W w 1 4 75 300
Compact Fluorescent:4:2'x2'Troffer/BIAX 40W/Electronic 2 2 72 144
Linear Fluorescent:EX:Existing 2'x4'Troffer/48"T8 32W/Electronic 4 17 114 1938
Linear Fluorescent:RX:Relocated 2'x4'Troffer/48"T8 32W/Electronic 4 5 114 570
Track:Track:30-W Per Linear Fool/Other 1 28 30 840
Total Proposed Watts= 3792
Section 4: Requirements Checklist
Lighting Wattage:
r] 1. Total proposed watts must be less than or equal to total allowed watts.
Allowed Watts Proposed Watts Complies
4341 3792 YES
Controls, Switching, and Wiring:
1-1 2. Daylight zones under skylights more than 15 feet from the perimeter have lighting controls separate from daylight zones adjacent to
vertical fenestration.
3. Daylight zones have individual lighting controls independent from that of the general area lighting.
Project Title:Weight Watchers Report date: 01/13/12
Data filename:V:\Energy_Calculation Data Files\Comcheck V3.8.1\120040.cck Page 1 of
Exceptions:
J Contiguous daylight zones spanning no more than two orientations are allowed to be controlled by a single controlling device.
J Daylight spaces enclosed by walls or ceiling height partitions and containing two or fewer light fixtures are not required to have a
separate switch for general area lighting.
❑ 4. Independent controls for each space(switch/occupancy sensor).
Exceptions:
J Areas designated as security or emergency areas that must be continuously illuminated.
J Lighting in stairways or corridors that are elements of the means of egress.
❑ 5. Master switch at entry to hotel/motel guest room.
J 6. Individual dwelling units separately metered.
J 7. Medical task lighting or art/history display lighting claimed to be exempt from compliance has a control device independent of the control
of the nonexempt lighting.
J 8. Each space required to have a manual control also allows for reducing the connected lighting load by at least 50 percent by either
controlling all luminaires,dual switching of alternate rows of luminaires,alternate luminaires,or alternate lamps,switching the middle
lamp luminaires independently of other lamps,or switching each luminaire or each lamp.
Exceptions:
J Only one luminaire in space.
J An occupant-sensing device controls the area.
J The area is a corridor,storeroom,restroom,public lobby or sleeping unit.
J Areas that use less than 0.6 Wattslsq.ft.
J 9. Automatic lighting shutoff control in buildings larger than 5,000 sq,t.
Exceptions:
J Sleeping units,patient care areas;and spaces where automatic shutoff would endanger safety or security.
iJ 10.Photocell/astronomical time switch on exterior lights.
Exceptions:
J Lighting intended for 24 hour use.
J 11.Tandem wired one-lamp and three-lamp ballasted luminaires(No single-lamp ballasts).
Exceptions:
Electronic high-frequency ballasts;Luminaires on emergency circuits or with no available pair.
Section 5: Compliance Statement
Compliance Statement: The proposed lighting design represented in this document is consistent with the building plans,specifications
and other calculations submitted with this permit application.The proposed lighting system has been designed to meet the 2009 IECC
requirements in COMcheck Version 3.8.1 and to comply with the mandatory requirementa in the Requirements Checklist.
Gregory R. Schnackel P.E.-President January 27,2012
Name-Title Signature Date
Project Title: Weight Watchers Report date: 01/13/12
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Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot# for locations for which a street address is not
available)
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
' � dti#r, A?'KT c ,p:+Fa`-�,il�+a� t""1' m,?i. •: 'i
Call structidn Supervisor Licese n
i
.:..,License:,cS t03353"..-
Ffastiic*�dtu CO.:
JOHN JONES, ,r
f8_CYPRESS:R6AD.*c
W 1 NDSgR:LOCK%,&06056 }
Exp"al�or 4/7/ZJ7'X