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HomeMy WebLinkAboutMiscellaneous - 1160 GREAT POND ROAD 4/30/2018 (29) p�6, foos i I d r T t a 9 r , r fi " a # .r. � � ,,. „$";.f ,�" —f �. b .. : (�Pt _. � .:P �" ��:45p„dr ��� F t �.,. Fr" � ,, ar•-a, PREFERRED CONTRACTORS. INC. October 29,2014 Gerald Brown, Inspector of Buildings North Andover Building Department 1600 Osgood Street, Building 20,Suite 2035 North Andover,MA 01845 Re: Brooks School Ice Arena Remodel Dear Sir: Attached please find the original stamped Final Affidavit for the above-referenced project. The electrical inspector, Peter Murphy, has toured the installation but has yet to sign off on the card. It's left on site for his use. Feel free to call or email with any questions. lJe ards, ferr Contr ctors,Inc. hn P Meade hn.Meade@PreferredMechanicalServices.com 223 Center Street, Pembroke, Massachusetts 02359 (781)293-1200/FAX(781)293-1207 FINAL AFFIDAVIT MECHANICAL DESIGN HEATING,VENTILATION,AIR CONDITIONING AND REFRIGERATION Permit No. 645-14 To the Building Commissioner, Town of North Andover, Massachusetts RE: Brooks School Ice Arena Remodel I certify that to the best of my knowledge, information and belief, the mechanical, refrigeration and cold floor installations at: 1160 Great Pond Road North Andover, MA has been installed in conformance with engineered drawings and specifications, and is in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. OF r 060PEI 83E 8. /ENG:21NE2E -neorge S. Peterso , PE 22683 CONAL EN MASS. REG. NO. c/o Preferred Mechanical Services, Inc. 223 Center Street Pembroke, MA 02359 781/293-1200 PHONE c/misc info/affidavit Verne G. Norman Associates, Inc. Electrical Consultants, Engineers and Designers 210 Winter St. Suite 301 Weymouth, MA 02188-3323 Tel: 781-335-4200 E-mail: vgna@vgna.com Fax: 781-335-5737 September 19, 2014 Mr. John Duffy Preferred Mechanical Services, Inc. 223 Center Street Pembroke, MA 02359 Project: Brook School North Andover, MA Dear John: The following is in response to your e-mail of September 11, 2014 regarding the aforementioned project. It is my understanding that the cubes are within site of the disconnecting means in the panel and, therefore, no additional disconnect switches are required. It may be helpful to install a placard on each cube identifying the circuit number and where the circuit originates on each cube so it is clear where the disconnecting means is located. Please feel free to contact our office if you have any questions regarding the aforementioned material. Very truly yours, Fier�ewie�P odd Frederick P. Goff, P. E. FG/nh \\SBS2011\Data\WPWIN\Brook School-North Andover,MA\Outgoing Correspondence\letter#1 to Preferred Mechanical.docx Datel-A(O.J.1. ............. 10670 vionr TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that..................................................................................... has permission to perform. ... ...... ... ................. mbing in the buildings of plu .. f y �, < ...... ...()A................................. ................ /1:............ North Andover, Mass. FeeJ.(A:=..Lic. No. 4....?N...... ...01(:.r............................................................ PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover MA DATE816114 PERMIT# I"�1 JOBSITE ADDRESS 1160 Great Pond Road ' tr JOWNER'S NAME Brooks School P OWNER ADDRESS 1160 Great Pond Road TELI 978-725-6300 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES® N0[] FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ?Q FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _ LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET 9 URINAL 6 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ®® INSURANCE COVERAGE: ,,I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW + 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A' PLUMBER'S NAME I Kenneth Kolifrath LICENSE# PIGNATLIRE MP❑ JP❑ CORPORATION Q# 2569 PARTNERSHIP❑# LLC❑# COMPANY NAME I Bride,Grimes Inc. ADDRESS I PO Box 776 CITY I Lawrence ISTATEF--M-A---1 ZIP 101842 TEL 978-685-1576 FAX 1978-685-7813 1 CELL 1 978-239 6728 EMAILbrideandgrimes@comcast.net 4 V �\ J'he Commonwealth offfassachuse#s , - - Depazrtinent o,�In�`�s�t�rrcrAcczc�ents Office Of.Ifivesil ateons 604 Washington Street .Boston.,MA 02111 wwly mass govIdla Wo rekey$,Compensation.bsivance Afidadt:BuRdercgIContractoro)Elec#rciciansl?XninberP ,A.ppUcant Wo nation Please.Print Ledhly 'Name(Businessforgaui'zalionftdividual}: /2X/ Mrx l Address: /-'fl? Ao y 776 Cz y/Safe/ftp: fill 'e�Jh� C C /,A A ' Phone#: 9 7� ���l 6 �L AV10: n.employer?Chec��e appropriate box: Type of project(required.): 1. a employer with 4. [1X am a general contractor and 1 6, n New construction. f employees(hilland/orpax�time) haveliiredthe sub-contractors 2-111 am.a sole proprietor or partnez listed on the attached.,beef� 7• IM Remodeling ship and`haveno.employees These sub-contractors have S. E]Demolition working forma in any capacity. workers'comp.insurance. 9. 1]Building addition [No work-ars'comp.insurance 5. ❑We are a corporation and its 10)]Electricalrepaixs or additions required.] officers have axerelsed.their 3.E1 I am.a homeowner doing all work right of exemption per MGL 1111 pXumbingxepairs or additions myself LEO Workers'comp. c.152,§1(4),andwehaveno 12.P Roofxepairs insurauc�recpiixed.�? employees.[No workers' 13.[]Other comp.insurance required.] xAnyajMoutthese�tionbelbwsfiowingtheirworkers'compensafionpolicyinfounafioa. pplicanttfiatchecksbox Zmustalso r Homeowners who smbmittbis affidavit indicatingtW ke doing allwork and then hire outside contractors must submit a new affidavit indicating such. xCDHtactom that cheAthis bob must attached an addifiond sheet shoedthe name ofthe sub-contractors andtheirworkers'comp.policy information. amanemproyst'tiicetispsovicXiitgworifeis'eompeizsationinsurane for myernpl'oyees .Serot i the alieyaractjabsite infarmadon. Insurance CompanyName;. /�' •.G - Cll` �'1� Policy#or Bel-ins.LIG.#" lo'cy ? g a Eiratzon Data. l S lob Site Address!!/I 4 Q C/l f7 �� City/State/Zip: PDX 7 Attach a copy oftte workers'compensation.poncy declaration page(showing-the policy number and expiratioa crate). Failure to secure coverage as requiredimder Section 25A.ofMGL o.152 can lead to the imposition of eximinallsenalties of a fm e up to$1,500.00 and/or one-year hnpxisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of uta to$25o.o o a day against the wolator. Be advised that a copy of this statement maybe foxwarded to the Office o£ Investigations of the Dor insnxance coverage vex%fication. do iiexeby certify uncle tried ins stye rties Of vajary tizat tlic information vrovidp'ed ove zs tine andeorreet. Si atare• f Data: 0 Z/-!Y Phone# ! (�— — 0lid use oitly. Do not write in tiais area,to be eomwleted by city or town ofcild City ox Town: PermMiceuse 9 Dsuing.A Authority(circle one): 1.Board of Health 2.Buildinpepartment 3.City/Town Clerk 4.Blectrical.Inspector 5.Numbing Inspector f.Other - - - Information and Instrnction Massachusetts General Laws chapter 152 requites aft employers to provide workers'compensation for their employees. •Pursuant to this statute,an arnployee is defined as"..•ever, person iii.the service of another under any contract of hire; express orimplied,oral ov written 0, An mpfoye is defined as"an individual,partnership,association,corporation or other regal entity,or any two ormore' of the foregoing engaged is a joint enterprise,and includingthe legal representatives o£a•deceased emplffex,.or t71e receiver ortnistee ofan individual,partnership,association or other legal entity,employing employees. however the owner of a dwelling house having notmore than three apartments and who resides then 4 or the o coupant ofae, dwelling house of another who employs persons to do maintenance,construction.or repair work on such dwelling house or onthegrounds orbuilding appurtenant thereto shallnotbecause of such employmentbe deemedto be art employer:" MGL chapter 152,§25C(6)also states that"every state or local Reensiug agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings iu the commonwealth fox any applicant who has not produced-acceptable evidence of compliance with the insurance coverage regalr ed" 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 Us chapterhavebeenpresentedtath6cgartractingauthority25 applicants Please f11 out the workers'compensaiion affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),addresses)andphonenumber(s)along with their certificates)of Insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orpartners,arenotrequiredto cartyworkers'compensationiasutance. IfanL'C O LP doeshave employees,apolicyis xequired. Be advised thatthis' affidavit maybe,submitted to the Department of Industrial Accidents fox confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. ifie,affidavit should ba returned to the city or town that the application for thepennit or license is being requested,not the De�attment of Industrial Accidents. Shouldyou have any questions regarding the law or if you are requited to obtain a yToxkexs7 compensationpolzcy,please call the Department at tho number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete andprinted legibly: The Department has provided a space at the bottom of the afddavitforyouto fill out in the event the Office of Ittvestigatzonshas to contactyouxegardiagthe applicant. Please:be-sure to fill inthe permit/license number whichwill be used as a reference number, In addition,an applicant thatmust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current PORGY information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or towir)".A copy o£the affidavit thathas been officially stamped or marked by the city or townmay be provided to the applicant aspzoofthatavalidafCdavit•isonfilel'orfa apexmitsorlicenses• Anew afddavitmustbefilledouteach year.Where ahome owner or citizen is obtaining a license ox'pe>nnitnotrelatedto any business or commercial venture (i•e•a dog license orict mit to burn leaves eta,)saidperson is N'OTmquired to complete this affidavit, The Office of Investigations would like to thank you in advance for your cooperation and should you have auy.questions, please do nothesitda to give us a call. The Department's address,telephone and fax number; T.dCQ oXkw?'althofMbsuchwotta De-PaxtmGut dbOU&Wal Accident Off toe ofTAYWrP-[ona 6b0 Waftg Streqt T01 c 01 0 617-72' ,49,00 W406 Yr-1•.•84£N - Revised 5 26-05 Fax • AC D� DATE(MMIDDM YY) �,,,,,"_ CERTIFICATE OF LIABILITY INSURANCE 04/292014 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 holders 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 CONTACT Susan Merriam Fred C.Chum,Inc, NAME 41 Wellman Street PHONE 978 3227296 FAX (978)454-1865 Lowell,MA U1851 A/C o Ext): AIC No): {800)2 MA 015 E-MAIL smerriam@fredcchumh.com ADD ESS: INSURERS AFFORDING COVERAGE NAIC A INSURER A: Commerce Insurance Company 34754 INSURED INSURER B: Admiral insurance Company 24856 Bride-Grimes,Inc. INSURER C: AM Trust Financial Group P.O.Box 776 ' Lawrence,MA 01842 INSURER D: 1 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2 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. rLTRINSR TYPE OF INSURANCE AODLSUBR POLICY EFF POLICY EXP POLICY NUMBER MM/DDIYYYY MM/DDGENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 DAMAGE TO XCOMMERCIAL GENERAL LIABILITY PREMSES EaEocaxrence^ $ 50,000CLAIMS-MADE a OCCUR MED EXP(An ,00y one person) $ 50 CA00DO11622-07 8/92013 8/9/2014 PERSONAL S ADV INJURY $ 1`000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2•000'0DO POLICY PRO- LOC $ AUTOMOBILE LIABILITY EeMBIace EDISINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED OZYD02 3/1012014 311012015 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON- OWNED PROPERTY DAMAGE $ Per accident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC S7ATU- OTH- AND EMPLOYERS'LIABILITY Y/N —.-_ 1'000'000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ C OFFICERIMEMSER EXCLUDED? � N 1 A WWC3089722 4/272014 4272015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1'000,000 It yes de=a under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE sent s Mst 29582 Cert Holder# ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • Inn m IR mbli vim] ' PLUMBERS ISN GASF IT..T RSM" ISSUE.S_..,TFlE FOLLOW If4Lf CENSE.:._ R£G S'F,E1�ED AS ,A PLUMBING CORP' j� K:;ErlETH J KO L I F ARTH yB(Q 'DEGR1;l�XS -<fJt. MP# 11.691 .. : 11 PALMER D `` 1e - t .. L K>rNSINCTON Nle 03833-673r 25Es9 "`fl5%01,11-6;:..>; <` 20$778 ;1:"O�COMMON WEALTH OF MASSACHUSETTS:.,,,. '. • • - • mor-311111111 Lei gom-10- M PLUMBERS . I+tD"GASP ITTE:RS ISSUES..THE FOLLOW[ LICENSE.:.. l:; L I CENSE"[3� AS A JO.UREd1 YUAN PLUMBEIT I; Z Eil171I J KOL I FRATH m :- ,Z 11 PALMER IYR.< u Ll KENS`l NITON NH' 03833-6731' 2T2[-.1>;i _ .-;05101-/.1:C:: .. i ; ► Uc sr..GLTH OMMONWEAOF MASSACHUSETTS. <= • Z go] - • • PLUMBERS ` GASFITTE;E�S j SSUES,..THE FOLLOWING L1'CENSE .;._. .: #... 1 11C15k.S < AS A,_.MASTER PLUMBER' h .Q Icy C;EN'M1tETH J KOL I FRATH 11 PALME�W:ItA`,. : :.:: I� N1 NGTOM ::NHS 03833 .6731 a� 0l::l..1:6::•«°: .;::zo8776 6•d £69L-999-9L6 'oul sawpe `apu9 e9ti:L0V1, 900 Date.... . . 42 982 NORTFI, 3?;f "�,� TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING �SgACMUSEt t This certifies that ........... .�+ .. -K. . .�..4 ..:......:.............. has permission to perform .. . .. .... .. . .... Y ....... ............:..... _ wiring in the building of ... . . ..... ..,.,t. . ... ............_. .................. at...1/.�..D... ... .. ..... ...I . ... ........ North Andover,Mass. Fee...3.a w..... Lic.No J`.l .......... WHITE:Applicant CANARY&17tlfqJA06 PINAX6.,tqAID t' r1 � The Commonwealth of Massachusetts �'� �1- Parrit No: O:i ice Use Department of Public Safety occupancy & Fee Checked- BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 heave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALLI ORHATION) Date jrQN& jr , � A.V l�q City or Town of�C�� JQJ�l To the Inspector of Wires: The undersigned applies for a permits to perform the electrical Work described below. Location (Street & Number) 1160] G(i('GAT POND V-o t'1r 0 Owner or Tenant an ooks Schoe f Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building e e- C. {nl k 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 No, of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA AboveIn- No. of Lighting Fixtures Swimming Pool grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency LightingBattery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Disposals No. of Pmts Total Total Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal ❑Other Connection No. of Water Heaters KW No, of No. of Low Voltage Signs Ballasts Wiring No. Hydro Mas}saag`e'Tubs ,No. off Motors Total AHP OTHER: '\G X�(a E, /X 116" t'1, �n t G\Y`�`�✓ INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Lia ty Insurance Policy including Completed Operations Coverage or substantial equivalent. YES NO ❑ .I have submitted valid proof of same to this office. YESCI NO ❑ If you have the ed YES,,please indicate the type of coverage by checking the appropriate box. - INSURANCE BOND ❑ OTHER F] (Please 9(Please Specify) (? / Expiration Date Estimated Value of Electrical Work $ 8,000 Work to Start6 -' L/ Inspection Date Requested: Rough Finalt/�-9_9 7 Signed under the penalties of perjury: FIRM NAME 6)^f N V`Bc4C C __LIC. NO. / f Licensee"PK,/,`(7 S A.-JJA SZ,1 Signature LIC. NO. /'Y� Address /-( c S Sr Bus. 1. No.,$O -6f-Z - Ss 9 �� vl,\ Alt. Tel. No. * 2,6// 014NERIS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Ve 09 Telephone No. PERMIT FEEWIF 4F Signature of Owner or Agent m Do Not Write In Here D M N For Electrical Inspector Only w rn r M n Street and No. n_ DName ............................:.............................. Z Electrician .................................................... PermitNo. .................................................... Comments .................................................... t Date. 2656 NpRTN TOWN OF NORTH ANDOVER pF PERMIT FOR; 'INSTALLATION �9SSgCHUSEt This certifies that . . . . l . . . . . -k . t.�. l 1 ( r, GIZ e /... . .�iC has permission for„gas installation . . .7.-e. in the buildings of . . . at . . &-t r �./�Cl�+,�. . . . ��. . . . . . ., North Andover, Mass. Fee. a No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i d�AS fNSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File •r Y Office Use Only C� a u4e CfgmmIInWr# of flaggar4USettO Permit No. Begartment of Vuhiic 35afetq Occupancy& Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date % ,I* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) > ir=S Owner or Tenant Owner's Address ZZ 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 ❑ Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work T al No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners I Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devices No.of Heat Total Total No. of Disposals Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices I Municipal El Other No. of Dryers Heating Devices KW Local [I Connection No. of No. of Low Voltage No. of Water Heaters KW I Signs Ballasts Wiring No, Hydro Massage Tubs I No. of Motors Total HP OTHER: 71 ". L U L ILIV � Inl 1 LA_ INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 72 NO 7 1 have submitted valid proof of same to the Office. YES _ NO _ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE �_ BOND OTHER C (Please Specify) (Expiration Date) Estimated Value of Electrical Work S Work to Start Aspeion Date Requested: Rough Final Signed under the Penalties of perju : r1 `~ FIRM NAM`.E, � ` 1 mom•'_ LIC. NO. �-- Licensee YVI�L.�A*A% tel Signature LIC. NO. ��� i �_ ` Bus. Tel. No. Address� d`�" s k All. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent) x•6565 . , �1 . w � J .. Q � " J 1 `Tvi�!� 6re�� 5`(,S -.6 o o 5 CERTIFICATE OF INSURANCE: PORT-L1 Lc. 1,33-10 {Q CSR EH 05/30/96 I PRODUCER 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND I I I CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE I (Bernard M Sullivan Ins I DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE I 118 Market St I POLICIES BELOW. II swich MA 01938 1 P I----------------------------------=-----------------------------------I COMPANIES AFFORDING COVERAGE I PHoNE508-356-5511 I ---------------------------------------------------------- --------------------------------------------'-=-----------------------1 I INSURED., _ I COMPANY LETTER A Commercial Union 1 II----------------------------------------------•-------------------- I I COMPANY LETTER B 1 LIGHT HOUSE PRODUCTIONS INC. ------------------------------------------- IDBA PORT LIGHTING SYSTEMS I COMPANY LETTER C (Todd Gerrish I------------------------------ I 13 Graf Road Unit #8 I COMPANY LETTER D INewburyport MA 01950 I--------------------------------------------------- I ( COMPANY LETTER E I> COVERAGES <=================------=============================================================================================I I THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY I PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO I WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO I ALL TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITt SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I I----------------------------------------------------- ----------------LIMITS-------------- I COI TYPE OF INSURANCE I POLICY NUMBER ( POLICY EFF I POLICY EXP 1 ILTRI I I DATE I DATE I I---I-------------------------------I---------------------------I---------------I-------------- ---------------------------------- I I GENERAL LIABILITY I I GENERAL AGGREGATE 12, 0 0 0, 0 0 01 II I I -------------------I--------------I AI [X] COMMERCIAL GEN LIABILITY I ABR408732 1 10/01/95 110/01/96 1PROD-COMP/OP AGG. 12, 000, 0001 II I I I I ------------------I--------------I I [ l CLAIMS MADE [X] OCC. I I I I PERS. & ADV. INJURY 11, 0 0 0, 0 0 OI II I I I I-------------------I--------------I 1 I [ ] OWNERS'S & CONTRACTOR'S I I I I EACH OCCURRENCE 11, 00 0, 0001 PROTECTIVE I I I I--------------_-----I--------------I I I I I IFIRE DAMAGE I I [ I I (ANY ONE FIRE) 150, 000 1 II I I I "-------------------I--------------I I [ I I I IMED. EXPENSE I I I I (ANY ONE PERSON) 15, 000 1 - --I-------------------------------I---------------------------I--- -----I--------------I-------------------I--------------I I 1 AUTOMOBILE LIAB I I I ICOMB. SINGLE LIMIT 11, 000, 0001 II II I I-------------------I--------------I I AI [ ) ANY AUTO I CBXBO1502 110/05/95 110/05/96 (BODILY INJURY I I I I [ ) ALL OWNED AUTOS 1 1 I ( (PER PERSON) I I I I [X) SCHEDULED AUTOS I I I I-------------------I-------------_I I 1 [XI HIRED AUTOS 1 I I IBODILY INJURY I I I 1 [X] NON-OWNED AUTOS I I I I (PER ACCIDENT) I I I [ 1 GARAGE LIABILITY I I I I-------------------1--------------I I [ I I I IPROPERTY DAMAGE I I I- --I-------------------------------I---------------------------I---------------I--------------I-- ----------I--------------I 1 1 EXCESS LIABILITY i I i (EACH OCCURRENCE I j I I [ ) UMBRELLA FORM I I I I-------------------I------___-----I I [ 1 OTHER THAN UMBRELLA FORM I I I (AGGREGATE I I - --I-------------------------------I---------------- ----I-------- 1--------------I-------------------I--------------I ISTATUT ORY LIMITSI I WORKERS' COMP 1 I I EACH ACCIDENT I I I AND I I I IDISEASE-POL. LIMIT I I I I EMPLOYERS' LIAB I I ( IDISEASE-EACH EMP. I I I---I--------------------- --I---------------------------I------- I--------------I----------------------------------I I ( OTHER I I I I I I I I I I I I I I I I I I I I-DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS-------- --------------------------------------------------1 IRE: NORTH ANDOVER'S 350TH ANNIVERSARY BALL - SATURDAY JUNE 8TH @ BROOKS ISCHOOL NORTH ANDOVER. BROOKS SCHOOL, TOWN OF NORTH ANDOVER AND NORTH IANDOVER 350TH COMMITTEE ARE INCLUDED AS ADDITIONAL INSUREDS AS THEIR (INTERESTS MAY APPEAR. 1 I I I> CERTIFICATE HOLDER <____________________________________> CANCELLATION <=========______________--------___________________=====I 1 = SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I 1 = EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL I INORTH ANDOVER 350TH COMMITTEE = 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE I IATTN BETSY M. LEEMAN = LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR I IP.O. BOX 111 = LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.1 INORTH ANDOVER MA 01845 =----------------------------------------------------------------------I I = AUTHORI REPRESENTATIVE /� I 1_ACORD 25-5 (7/90), � � 1