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HomeMy WebLinkAboutMiscellaneous - 1 FAULKNER ROAD 4/30/2018N) Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING I.e* 0 This certifies that .......... ....... ........... has permission to perform .......... Jam.l.. ��nr ............................. wiring in the building of IT ... 4�7 ............................................... at .... .......... /�b ................... , North Andover, Mass. Fee 55.i� .... Lic. No. RY.q. A .......... iL* E- CrRICAL I PECTOR Check # C/� //) Official Use Only ommonweatilt o1 nVaJeac11.ueelle 2CC �� Permit No. D QQ epartment W Wise Service9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev. 11/99) (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C//MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: t 6o G City or Town of: /Lvv,E i' A7V tDo,6e& 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) / P410 I K1,12A- a a 1+7\( QifVVU Owner or Tenant Owner's Address Telephone No. q 7j�'— &*3 - 3 & fS Is this permit in conjunction with a building permit? /I Yes ❑ No P' (Check Appropriate Box) Purpose of Building A414,71 /Z a&-, Utility Authorization No. W© -41�- Cvlc e . 11 Existing Service 70 Amps Volts Overhead ❑ Undgrd P� No. of Meters 1 New Service P�OV _ Amps oW l6t0 Volts Overhead FLr Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: "Irk oa4Pl►�/ �lBt.tf2d� '� /A� may No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA Above In Pool ❑ ❑ No. of Emergency Lighting No. of Lighting Fixtures Swimming gmd. gmd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number _ _Tons _ _ _ KW _ No. of Self -Contained No. of Waste Disposers Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal E] Other Connection Security Systems: No. of Dryers Heating Appliances KW No. of Devices or Equivalent No. of Water No. of No. of Data Wiring: Heaters KW Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: Attach additional detail if desired, at- as required by the inspector of Wires. 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 sudh coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ;t Inspections to be requested in accordance with MEC Rule 10, and upon completion. 1 certify, tinder the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Lt%`l/.*M LIC. NO.:l/' Licensee: 44111 ✓yn 7— Signaturexi/1,�,.✓► LIC. NO.: �.qwy 7y' (If applicable, enter "e.rempt" in the licence number line.) - -- - Bus. Tel. No.4/2- S�L�- Address: S,-; SJ—_ LJ&4c,44a wy;_ da! Alt. Tel. No.:2fjnf -A115 &l'efr 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 hereb waive this requirement. I am the (check one) owner [._I owner's agent Owner/Agent Signature f `' �il✓f¢' Telephone No.y e— �k3' IJW6 PERMIT FEE: $ Date. Oc/. / ?A ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION T h i s c e r t i f i e s t h at has permission for gas installation in the buildings of ................ at . . / -. r - 7, .1 ........... NorthAndover, Mass. Fee. 4r,!�2 Lic. No..?F�97.. .. . A Check 4 00 21 7836 .0 i,. INIA%ACHUSEITSUNME IAPPUCATONFORPM'Vl TTODO GASFITTING (Type or print) Date 1011-111111..___� NORTH ANDOVER, MASSACHUSETTS Building Locations - n; i60i/A ' Permit # Amount $ as - Owner's Name New ❑ Renovation ❑ Replacement E Plans Submitted ❑ (Print or type) �y I Chec ne: Certificate Installing Company Name .9iY�� A.Gf/yM,�%t/h' 'W"dide� �1 �• Corp. Name of Licensed Plumber or Gas Fitter �9&Agj,�,F j42eedikf— ❑ Partner.. ❑ Firm/Co. INSURANCE COVERAGE Check onp,' I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked yes, please i ocate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the :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 m} 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 StaYGas Code an Chapte,614,.Af the General Laws. By: Title City,Town :APPROVED (OFFICE USE ONLY) anature of Licensed Plumber Or Gas Fitter ITI"P 4w -fig ❑ Gas Fitter tense i um er HMaster Journeyman Pilo MWMAWG • . .■________.■_.__o.__._i (Print or type) �y I Chec ne: Certificate Installing Company Name .9iY�� A.Gf/yM,�%t/h' 'W"dide� �1 �• Corp. Name of Licensed Plumber or Gas Fitter �9&Agj,�,F j42eedikf— ❑ Partner.. ❑ Firm/Co. INSURANCE COVERAGE Check onp,' I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked yes, please i ocate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the :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 m} 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 StaYGas Code an Chapte,614,.Af the General Laws. By: Title City,Town :APPROVED (OFFICE USE ONLY) anature of Licensed Plumber Or Gas Fitter ITI"P 4w -fig ❑ Gas Fitter tense i um er HMaster Journeyman _ TJj,t��e Co momi!ealtA oflk�=9—durset[S . z ejltTrb11b t Qf IndrtS*W eACC IrPJIt•4'' �" O, Tice of llNeStlgoOnS, ` 600 WasOzgtoie S.freet ` Boston, MA 02111 .'� 7M10rp mass gOvIdla Workers' Compensation.Insm=ce A%4i*s- derdConftcto,r +'Iectrfcizins/Plumtiers Annlicant Information'.. 'Please Prtnf Li'eibiv Name (Business/0;gpai zadonnadividwd). A 1/ Address:_,�i Al !%/1�jraY1,D City/Siate/Zin:/Sl.+lar/ #: Are Y as employer? Check the appropriate. bax .. , . ' .: • ' .: , :::.. , , of ra W4 (r n = p (moi : 1. 1 am n e l Kith mP ° ❑ i tem a g=.— S, COIi$BCbr BIId = - 5: •0 T%w construction employees (frill and/or paW; ime).s 2.0 I am a sole proprietororpartner- - : have hired the 1istt d;on the atiached:sb�t.. 7. Q"Remodeling ship and have no emptayoes - - . - sue 8• .0Demolition wonting for me in any capacity. employees and have workers'" 9• BuBding addition (No wo&M'.comp: insurance required.] corm. insurance.t We acct a cotporetiah. and its 10.[j lectrical repairs or additions 3. ❑ I am a homeowner doin"g all'work ot5cers "have mcercised then 1 l:lPlumbing repairs or additions• m f. [No workers' " y� �P• Fight Of exemptioh — MC1L.- � � 120 It,oufiepaus . insurance required] 1 c. i52, §1(4) and we have no : l3 Other'' employees.•[Nuwioj,06W • -O _ ' -comb: insurance'teaairedl .. . - TAW applicant that cbwb box tit must Om lilt out the sicft bdw *owing t ift woiiaxs' coin policy btrot =d0it. TAW who suborn Idis affidavit ind oft day am dela$ all work acid that bice outside Wetrd t= xnm submit n newaffidavit irtdca ft such. Contractors that cback this box am nuacbed attaddidond Awsbo wiaa dm mane. oFihe iaaars and_ stote•arhaher or tmt those eadties We � M employees. if the wb-centradors have cmployer^s. they must provide char wathas' comp. pocky mu nba: I am an employer that is providing iporkers' compensation &stasis for my employees: Bidoiv Es nice policy andJob site i inforinadon. Insurance Company wame: Policy # or Self -ins. Lit:. #: u%Ls xa���� Expiration Job Site Address: Ci<y/Stat mp• egsb6L— Attach a copy of the workers' compensation policy declerat60 page (sboivbeg the policy number and expirntion date). Failure to secure covtoage as required under Section' 25A tifMGL c.152 can lead to'the im0osidan-oferiminal.paireltiesofa fine up to $1,500.00 and/or one-year Wit, as well.ss eivil.penalties in the foam of a'STOP WOitK ORDffit and a fine of up to X250.00 a day ag#inst the vioiatoi:- Be advised that a copy of this stat+mmidt May be•foFwarded to the Office of Investigations of the DIA for insurance covemip verification. 1 do hereby cei#fy thepd= and psnaN _ of erJury that the iaformutiiorr provEded above is tare and correct Official use onE.Y Do not iw*e En this area, to be �mplaW by city ori toinn afjidaL City or Town: # Issuing Authority (circle one):. 1. Board of Health 2. Building Departmcn't 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector b Other Contact Person: _ Phone #: �_ r 0 ACORV CERTIFICATE OF LIABILITY INSURANCE DA /4/20E1MMIDDIYYYY) F 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. 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 pol)cy()es) 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 endorsement(s). PRODUCER CONTACT Gail Cregg NAME: Fred C. Church, Inc. ma Street 41 Wellman Street PHONE 978 3227266 FAX (978)454-1865 Lowell. A1C No Ext): A1C No): E-MAIL gcregggredcchurch.com ADDRESS: (800) 225-1865 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Selective Insurance Company of South Carolina 19259 INSURED INSURER B: Selective Insurance Company of the Southeast 39926 Andover Plumbing & Heating Co. DAMAX PREMIREMI ESES S( RENT 100,000 Ea occurrence) $ INSURER C: PO Box 262 Andover, MA 01810 INSURER D: INSURER E: INSURER F: A COVERAGES CERTIFICATE NUMBER: 16531 REVISION NUMBER: 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAX PREMIREMI ESES S( RENT 100,000 Ea occurrence) $ CLAIMS -MADE 171 OCCUR MED EXP (Any one person) $ 10,000 A S1827324 10/26/2010 10/26/2011 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-- COMP/OP AGG $ 3,000,000 POLICY P O LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ l NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION X I WC STATU- OTH- B AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y /N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA WC7251991 10/26/2010 10/26/2011 TORY LIMITS ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below 500,000 E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Plumbing & Gas Inspector 1600 Osgood St, Bldg 30, Suite 2-36 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01645 AUTHORIZED REPRESENTATIVE Client # ' Mist # 16t 31 ACORD 25 (2010/05) Cert Holder # 34111 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD