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Home My WebLink AboutMiscellaneous - 1 Royal CrestI Date........... ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING AVW -P- Uee4-a4c/ This certifies that 'h as permissionto perform gA. "t, ............................................................................................. wiring in the building of ........... V2- p - "'*"***"* .... p ................................................... .at ... �cy&4A NSJI DR. ur,-A� k -N ................. .......................................... .. �_Iyorth Ando er M Fee.,Y�5� ....... Lic. No. 61 ...M.6 ........ RECTRIC,�L INSP Check # 12 Commonwealth of Massachusetts Official Use Only - Department of Fire Services Permit No. I 45" Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank 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 INMK OR TYPE ALL INFORM4TIOA9 Date: A Ue4 U _5 t vk 6 , I City or Town of: NORTH ANDOVER 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) 'S® 2-0 U Q-( C.C-e- S+ 0 2 Owner or Tenant A rM i C © 11.61'L � jA► N DOv-e-r L.L C . Telephone No. Owner's Address Ou i (Olt nc� ! Is this permit in conjunction with a building permit? Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Yes ❑ No V (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. 'of Meters Location and Nature of Proposed Electrical Work: C; 0-cK 4- e Stz-1cc0 Car)rr e-C-(-oor)'S ► t1 PJ ---0 . & 1,tdrz i c, ;a -to-+ I L n e - yo i)cc e. 4) t r r-4 o S 1-S u rs cL C,t r(.v -� b r t k e r S Fe c D i n cj "fi S e- v n 14-- ' Completion ofthe followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires Attach additional detail if desired, or as required by the Inspector of Wires. E�stimated Value of Electrical Work: �®d i No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above F1 In- El o mergency Lighting rnd. rnd. Battery 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 Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number � � �� Tons KW No. of Self -Contained 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. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 06 (When required by municipal policy.) �-' ork to Start: 8 (a le I 1 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 foe 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: INSURA-NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, ander the painsyand enaltie�s/of erjury, that flee information on this application is true and complete. FIRM NAME: D A 1.4 er ( p, V t �) e— t ,e -r- -►2_ i G LIC. NO.: A 15-79'/ Licensee. (}�jl I �`f e, Signature L% P Vt'cc,(Ae- LTC. NO.: 3186 (If applicabe enter "exempt" in the license number line.) Bus. Tel. No. Address: NO D R I C S--- WCL -1 [Ode -1M m 14- 6 a U j Alt. Tel. No.: -504- � d� *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally -�� required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ z`'� ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall. be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors_Signature: Date: SERVICE INSPECTION: ` Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: c Inspectors Signat e: Date: FINAL INS CTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: v Date: e — -2- 2 — /,— DEB WEINHOLD ... TOWN OF MRRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts ` Department of Industrircl Accidents Office of Investigations IF 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Z) p%1 IL 1' y1 �,- e e t�Li .c Address: City/State/Zip:t).L('y'LC,,-WV) MA- Phone#: Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with � 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. Q New contraction 7. ❑ Remodeling 8. Q Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.E] Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. f -Homeowners who submit this affidavit indicating they sie doing all work and then hire outside contractors must submit anew affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company 1, MSv re, cn c Policy # or Self -ins. Lie. #: LC SGC i95 3 a(Y�q Expiration Date: (I 111 Job Site Address: -5c) c2Nc,_A 'D fL ,City/State/Zip: G 1 g 4 S 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 hereb certry under the pains and penalties ofperjury that the information proviCCdeed above is true and correct. Signature: `� Date: 1 g - Phone #: 5Q8SQd(t a 9 C 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer 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 an 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 bode emed to be an employer." MGL chapter 152, §25C(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.has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(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 partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure 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 Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has 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 applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit 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. 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 call. The Department's address, telephone and fax number: The Commonwealth of 1\4a ssa chv..setts Department of IndusWaa Accidents Office of Investigations 6.00 Washingtou Street Boston, MA, 02111 Tel, # 617-727-4900 eyt 406 or 1-877:,MA.SSA.BE Revised 5-26-05 Fax ## 617-727-7749 wWw-wass.govfdaa „l' B 14,eo o5Cec3oO r COMMONWEALTH OF MASSa['Nr Q=-rr.o O A�®CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DdYYYY) TYPE OF INSURANCE 8/26/14 THS,CE!RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS PcRTIFICATE 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(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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: LESLIE HA 4NON James O'Connell Insurance AgenPHONE (978 667-6150 IAICFAX No. (979) 667-0587 ADDRESS: JIMINS@OCONNELLINS.COM 572 Boston Rd Unit 7 INSURE S AFFORDING COVERAGE NAIC# Billerica, MA 01821 INSURER A: Merchants INSURED INSURER B : A. I . M. Insurance DANIEL P VITALE ELECTRIC INSURER C: INSURER D: 190 DALE $T INSURER E: WALTHAM, MA 02451 I NSU R ER F: COVERAGES CERTIFICATE NUMBER: 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 ADDLSUBR TOWN OF NORTH ANDOVER MA POLICY NUMBER POLICY EFF M/DD/YYYY POUCY EXP MM/DDIYYYY LIMITS A GENERAL LIABILITY XCOMMERCIAL GENERAL LIABILITY CLAIMS41AADE 7 OCCUR 13OP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 1,000,000 PREMISES occurrence) DAMAGE TO RENTED $ 500,000 MED EXP (Anyone person) $ 15,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS COMB INED S INGL E L IM T Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PeOacE TY DAMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� OFFICE RIMEMBER EXCLUDED? (Mandatory in NH) If yyes describe under DESGRIPTIONOFOPERATIONS below N/A WCC5006538012009 10/11/13 10/11/14 X WC STATU- OTH- E.L. EACH ACG DENT $ _100,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ELECTRICAL WORK rFRTIFIrATF Hnl nr-P CANCELLATION © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST AUTHORIZED REPRESENTATIVE , NORTH ANDOVER, MA 01845 LESLIE HANNON © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: