HomeMy WebLinkAboutMiscellaneous - 110 Kingston Street 0
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Date......l U..... .t.1..................
OF NORT�y
oL TOWN OF NORTH ANDOVER
o p PERMIT FOR WIRING
- ,s3ACHU5��
This certifies.that ,.,.....!......�� R
......................................................................................................
has permission to perform .......... .-A.-J.....C.
.........................................................
wiring in the building of...'-! ?!:`--' ..s?................................................................................
at ...........I.w.........� ..... .. North Andover,Mass.
2 ............... .....
Fee........�1�;.......Lic.No. Z6-101.--................................................................................
ELECTRICAL INSPECTOR
Check#
2 5 3 -= -
l_ommoru.eJM of J�&4.iachrje l 0f7ricizl Use Only
'� n, arEmerE o ire Services PCI-Mit No. G��
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS --
y [Rev. 1/0"1) (leave blank)
All work to be performed in accordance with the idzss= 'rn::etts ED r ca!Code(1vfEC), 527 CMR 12.00
("LRASE PRINT IN INK OR 7Y :1L.L'�/WORMATIO�'�!) Dale:
City or 'gown of': _ �1 e To 1' e !,,, 4.,�C1... FYires.By this application the undersigned e.n es notice 0f his or her intention to perforn clecir is I ,.ark described bolo•::,.
Location (.Stl•eet& f�,urnber) �-
Owner or Tenant Telephone No.
(limbi• c drr {r•ncc „� -
Is this permit in conjunction ivitli a `buil-diriy` permit?? V , �-
I -`= [_j mo (Check -i ppropriate Bo:) ---
Purpose of Building �Gl„ "'iility Authorization No,
Existing Service
AD Amps /eat, /q,1tj V0Its Overhead n Undgrd �� No. of Meters _
New Service �p� Amps ��/Q2-aVolts Overh^ad Dj Undgr-d IJ No, of 1�eters
Nuiuber•of Feeders and Ampacity
Ic
Location and Nature of Proposed Electrical Work:
R, — C.o .i_iar,r, ,,ilei,ink ra ie rr be waived by rr.e_a=
�- - IN'0. of T.•.• .
I�10, of I�.eCeSS2d Lii,iiiil^bites to. of CCU.Susp, (Paddle) Farls " "
Transformers
No. of Luminaire Outlets lira. of Hot Tubs Generators-
No, of I_,uminaires
5ls'i.nmirtQ Poo( Above In - 1_x'0.oTZrnervency rg,nn
�rnd. �, or II d,_❑ )Batten, Units
No. of Receptacle Outlets lNo. of Oil Burners 'FI Lr AL:.-R. MS ll�'o, of Zones
No, of Switches INr.. of Gas Burners —�'No. 0f Uett anon and ---I
_ Initiatins, Devices
INo. of Ranges
Total of Air Cond, Devices N • . Q
Heat urn
P p Number 'Pons ICVr
No. of Waste Disposers .................................................. ............. -�`OLc`If.��lf1ContatnDevices
d F
—_ Tata).,: I I ror;;:..lertinQ evices t
l.No. of Dishwashers Space/:?.rea Heating k��r 'i_,�,al 'luriicipal r;lyr — 1
Connection '^
- R�
{Ne. 0f Dryers ----...---------- —_`,-- ` . 1.
Ideating Appliances K��' -- I:.s:"
_ _ wr, iI;VIC`SOr F('n;•>'213i1t I -
i\oLHydro
of )'ator INo. of No of -_------==--=----------{
rs K`,1 Pall ' --a '•i:
Signs acts __ i�'o. a; D vices or
sage Bathtubs lNo. of Motors Tor:) HP : com .1n cations 'r ino:
\'o. of Devices or- E-Mlivalent_ ._----
r to pinch addili�ro!detail fj'"cssire;; or os reyuL 5y th.e Ir. peC!or r,(11'ir<..
Fs:irnated Value of L leciT'cal \'ft•arl.: -IDC)t _ (��'h.en required by rnunic aal policy.)
r:;: to Start: 1 1� L-,_pec.ii•ons t. e- quested in -c-ordance with MF'-C Rule 10, a:-,d upon o nnletion.
I`SUR_4ti'CE COVERAGE: liniess w:aiveci_ .tie o,:; f
. •- r,.e per:rrt for the performance ofIectrical work may issue
D:OOfOf lla_Dlhry IP.St:rance rrlClll i'. 'CnID_'�lJ :,:,oration" over or itS 5ubsiaritial equivalent.
tSuch Iorc-c a ,.S rt' - :a• :� ln� o:--. :SIn�� OiCef1
_ ;i.. _
C ..�c_,_O ::SU? .NCE F-1/ BOND ❑ � ❑ r _ -
II rcIe�r�n1? unger p.:rs and =ralfies'c perju_ryor`
and compleie._NAME: � a�e �
_ _ C. NO.: o
Licensee: `
i_nahrre--` LIC. NO.: �C
ab! ?7iie• " oMr) ir. 'he.!i ease r:.•,��er
Address: q � �� � (- ��'�\,� Gus. Tel. No.: - 0a
P� _ .41t. Tel.
*Per!v1.G.I... c. ;-7, s. 57-61,security wo-: :;quires .)_ _ bent o Public Sa;:a.; - ._.__._ e. L,ic, No. —
OWNER'S EN'S 111;RA.NCE;WAIVER., I -.: ,. ::•.vare ...-. ...e t.icensee do s not r :' ;., — - ---
. ;:: insurance
requir-M by la`:;. By my siEillature below, -:_.reby v.:: ,._:: s requirement. I am ti:e ne ovmc.
Owner/Agent
Signature ^ 'r 1e_hone No._ -- — L'P.-P'11IT S _,
i
.The Commonwealth of Massachusetts
Department oflndustrial.Accidents
d I Congress Street, Suite.100
Boston, .AVIA 02114_20.17
)Porkers' Compensation Insurance www mass'.gov/diaAffidavit: Builders/Contractolsi.Electricians/Pltunbei-
Alicant Information TO BE FILED WITH THE PERiVIITTING AUTHORITY.
NaIne (Business/Organization/Individual): m Please Print Le iblV
Am
City/State/Zip: --
r2.
1_ �Ohone fl:_ t , ' C jrl G ,
17an employer?Check the appropriate box:
1 m a employer with Type of project(required
employees(full and/or part-time).* )
❑I am a sole proprietor or partnership and have no employees working for me in �' 11 New construction
any capacity.[No workers'comp,insuance required.] 8. 0 Remodeling
3.[:]lain a homeowner doing all work myself.[No workers'comp.insurance required.]t
`�• ❑Demolition.
4.[]I am a homeowner and will be hiring contractors to conduct all work on illy property. I will
10 El
ensue that all contractors either have workers'compensation insurance or are sole Building addition
proprietors with no employees. 1 l.Mj`Electrical repairs or additions
S.r7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12 �]Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.#
13.[]Roof repairs
G.L]We are a corporation and its officers have exercised their right of'exemption per MGL c.
152,§1(4),and we have no.employees.[No workers'comp.instuance required.]
*Any,
Other
-----
Any applicant that checks box 91 must also fill out the section beloNv showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a n---- ewaffidavit 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 must provide(heir workers'comp.policy number.
-
lain an employer that is providing workers=C01111)e11satiOn IIISu1•ance.for Illy employees. Below i.s the policy and job siteIn forination.
Insurance Company Name: Q
� Policy#or Self-ins.Lic.#: Lk)C - r
a ---_
a -.o (? - L7Gr � -'�1 C
�__�_ _� _ Expiration Date:_
Job Site Address:__
__City/State/7_,i �� (} i�
Attach a copy of the workers' corn el policy declaration rage sho�viu�= p:�?
Failure to secure coverage as required under MGI,c. 152• l biminal violation(Showing the policy number and expiration date).
and/or one-year imprisonment,as well as civil penalties in§he form Of STOP WORD ORDER anle d a file of lip to$2e UP to 00.00 a
day against the violator.A copy Of this statement may be forwarded to the Off, of Investigations Ofthe DIA for insurance
coverage verification.
I do hereby certify der the ains and penalties of peljuly that the i1 forinatiolt provided above is trite and correct.
J
Sign ature:
Date: 7
.Phone
Offcial use only. Do not write in this area,to be completed by cit},0r 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 S.Plumbing Inspector
6.Other
Contact Person:
Phone#:
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07/01/2015 09:21 Neil & Neil Insurance Agency (FAX)14137316629 P,001/001
ACCO� CERTIFICATE OF LIABILITY INSURANCE °A0710112o 5Y'
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 certiflsate holder Is an ADDITIONAL INSURED,the polley(les)must be endorsed. If SUBROGATION 18 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 Ileu of such endorsement e.
PRODUCER CONTACT CONT, David Jerry
Neill&Neill Insurance Agency Inc PHONd
882 Riverdale Street (413)732-4137 (413)731-6828
West Springfield,MA 01089 AODRE :
IN R AFFORDING C V M NAIL N
a E State Auto Insurance Company STA
INSURED Michael Fareill Electrical E Acadia Insurance Co; 31325
9 Applewood Gane
Methuen,MA 01844
aU ER 0,
N
. INSURSR F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 1S 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 TYPH OF INSURANCE POLICY NUMaaADDLISURRI R M r LA LIMITS
A GENERAL LIABILITY SOP2745517 0811012016 08/10/2016 EACH OCCURRENCS d 1,000,000
1A I To"INT11
COMMERCIAL GENERAL LIABILITY a 50,000
CLAIMS-MADE V OCCUR MED EXP(Anyone arson i 51000
PERSONALS ADV INJURY $ 11000,000
OENERALA00RE0ATe i 2,000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP A00 f 2,000,000
POLICY IR LOC i
AUTOMOBILE LIABILITY
RgED SINGLE LIMIT
ANY AUTO BODILY INJURY(Par Parson) I
ALLOaWNED SCCHROUL90 BODILY INJURY(Per eWdanq i
AUTOS NON-OWNED 6
HIRED AUTOS AUTOS ! e i
UMBRELLAUAB HOCCUR EACH OCCURRENCE i
RXOESS VAR CLAIMS-MADE AOGREGATE i
DED RETENTION! S
_WORKERS COMPENSATION WQ-20-20.001481-06 03120/2018 03/2012016 A u• I I OTH.
AND SMPLOYRRS`LIABILITY
ANY PROPRIETORIPARTNER/EXtCLRIVE N/A 91,EACH ACCIDENT 1 100,000
OPFICHRMHMBHR EXCLUDED?
(`Mandatory In NH) E.L.DISEASE•EA EMPLOYEE b 100,000
ff ea deacdbounder
E,L.DISEASE-POLICY LIMIT i 600,000
OESCRIPTION OF OPHMTIDNS I LOCATIONS I VBHIOLBS(Attach ACORD 101,Addltionei Remarks Schedule,It more Spice M required)
Faxed to: 978.682-1480
i 1
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TH5 AROVB 066CRIDED POL10166 Bfi CANCELLED BEFORE
Town of North Andover THE EXP(RAT(ON DATE THEREOF, NOTICE WILL BE DELIVERED IN
1600 Osgood Street,Building 20 ACCORDANCE WI E POLICY PROVISIONS.
Suite 2035
North Andover,MA 01845 AUTHORIZED REPRES TA 5 r r
,
®1988.2010 ACORD C PORATIO , rights reserved.
ACORD 25(2010/04) The ACORD name and logo are registered marks of ACORD
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