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HomeMy WebLinkAboutMiscellaneous - 12 ROYAL CREST DRIVE 4/30/2018 (2) 1Z � 777\ OB UIL DII, i I 1 I�, Date.1�� ......TI........... J ' OF NORT�y TOWN OF NORTH ANDOVER c * PERMIT FOR WIRING �sSACHU This certifies that ..!.... .`. ....Y.. I �Ie.. .'..��-............... .................... has permission to perform .... P. i.. ..t`§. ..... .�J.�?. -0�'....................... wiring in the budding of.......... ..Y.('.X..�....0-�..�............................ at -.. ....... +. ..... ..5 .............................. rth Andover,Ma Fee... ............Lic.No. � .......... ..V..... 7 , 5ELECTRICAL INSPECTOR Check# ' t 13031 i Commonwealth wealth ofr=Massachusett Official Use Only Permito. N ��b Department of Fire Services " Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (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 ININK OR TYPE ALL INFORMATION) Date: De-C A , I q 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 electricaj w rk described below. Location(Street&Number) SO YLC t,i o tb 2 C f�c t. 12 Owner or Tenant A(--,\,C C` mc)r 1 Prn A N oGtr-et' U-c , Teleph ne No. Owner's Address 8 U 1 r1 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❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed EIectrical Work: NO-LK L Jt c-6-QG(�J Con n-e(L-60-) 15 its -k 7 -Skboo-r()( ��e e hzi c Y�eeti-�. Vbl mac{P C&-v,at. b r-e-cG 6 r-S coo v� e o ff f Completion o the ollowin table maybe waived by the Inspector of Wires.p g No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA r. 4 No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Bur,-iers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: ....................... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No..of Dryers Heating Appliances KW Security t o.o Systems:* evi es or E uivalent 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 c OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. + Estimated Value ofiiElectrical Work: ,G (When required by municipal policy.) Work to Start: 1Z„`ma t t Lt 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 the 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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: .t)A-tu ice( P %" LIC.NO.: A15-19q Licensee: ()g;jeI (> V j W t; Signature � LIC.NO.: 56 L (If applicable enter "exempt"in the license number line) Bus.Tel.No.: Address: d D �-lc S4- �A-�c.i ,-L r, VA , 111 A Cha�5Alt.Tel.No.: b *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.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 [PERMIT FEE: $_ Signature Telephone No. j The Commonwealth of Massachusetts - Department ofIndustria.l Accidents Office of Investigations_ 600 Washington Street Boston,HA.02111 www.mass.gov/diff ' icianslPlumbers Workers' Compensation insurance Affidavit: Builders/Contractors/El p�ase Print Le bl Applicant Information i I _ Name (Business/OrganizatiorAndividual):—� �Aro\ P V\ �l le-t47L-i Address: l n'l d �)PA ra _ L(ti1�w) MA- ®cQS) Phone#:City/State/Zip: ��A ' Are you an employer?Check the appropriate box: Type of project(required): _ I am a employer with 4. ❑ I am a general contractor and I 6, E]Now construction 1.❑ employees(M and/or part-time).* have hired the sub-contractors 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. . These sub-contractors have 8. E]Demolition ship and'have no employees working for me,in any capacity. workers' comp.insurance. 9, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their per right of exemptionp MGL 11.0 Plumbing.repairs or additions 3.❑ X am a homeowner doing all work g c. 152 §1(4),and we have no 12.Q Roof repairs myself.[No workers' comp. insurance required � employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. 4. TContractors 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. M ,� mac t^�cn C Insurance Company Name:. , i '� ( Expiration Date: Policy#or Self-ins.Lie.#: SG� t9`7 Job Site Address: 5 6 `C2 oue-;l Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a the form of a STOP.WORK fine upt o$1,500a d and/or one-year e violator.onment,as well as civil penalties Be advised that a copy of this statement maybe forwarded to the Office o and d a fine of up to$250.00 a day against Investigations of the DIA for insurance coverage verification. I do h.erebucertify under thepains andpenalties ofperjury that the information provided above is true and correct. Date: Si atare Phone#: 08—S �^ Official use only. Do not write in this area,to be completed by city or town official. O ff y i City or Town: Permit/License# ! Issuing Authority(circle one): 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 6.Other - �i Phone#: Contact Person: J i # COMMOEALTH OF MASSACHUSETTS NW 80i4t�D OF ELEG`TR I l AN I. ISSUES THE-•FOLLOWING LfC_ENSE RE6'I STERED MASTER ;EL�E�TRI C I AN .4 /r �Z t DANIEL F VITALE } y .: X190 DALE STt f WA THAM,_ 'M ,02451 3773 1579:9 A o7/3�116 3500 ,COMMONWEALTH+.OF. MASSACHUSETTS ELEQT I C 1 ANS a ISSUES THE FOLLOWING LICENSE No. AS A REG JOURNEYMAN ELECTRICIANlz :' icc DANkEL P VITALE i' 190 DALE ST r L 4 ♦ J WALTHAM MA'.0.2451-3773 j 31850E 07/31, 35002 ) i i; /i�eeo o5Qe CERTIFICATE OF LIABILITY INSURANCE CERTIFlCATE HOLDER THIS14 ��TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGH pUTHOWZES AIV T AFFIRMATIVELY OR NEGATIVELY AMEND, EXT CONORRACT ALTER OTHE ISSUINGFINSUR0 ISER(S), A POLICIES KATE DOES NO CE DOES NOT CONSTITUT A THIS CERTIFICATE OF INSURANCEto to PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER• otic les must be �e on this certificate does not AMON IS conferDrights t tthe PORTANT: If the certificate holder is an ADDI110NAL INSe UE�'an endorsement. A statem tie terms and conditions of the policy,certain policies may q coNTACT LESLIE HANN certificate holder in lieu of such endorsements. ON 'NAME: FAX (g7$) 667-0587 PRODUCER PHONE �978) 667-6150 AI NO James O'Connell Insurance Agen E-MAIL JIMINS@OCONNELLINS.COM ADDRESS: NAIC# 572 Boston Rd INSURE S AFFORDING COVERAGE Unit 7 INSURERA:Merchants Billerica, MA 01821 INsuRERB:A.I•M• Insurance INS UREDI NSU RER C: DANIEL P VITALE ELECTRIC INSURERD: E ST �'90 DAL INSURER E.. WALTHAM, MA 02451 INSURER F REVISION NUMBER: OD COVERAGES CERTIFICATE N UMBER: CT ' OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT HEREIN S SUB ECTPTO ALL THE TERMS, CH THIS THIS IS TO C=M, THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ED NAMED ABOVE FOR THE POLICY PERI INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TER CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY T ou OD BY DOSIYEXP LIMITS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.ub LIMITS SHOWN MAY HAVE BEEN REDUCED PAID CLAIMS.`yp INSR POLICY NUMBER $ 1 000 000 j LTR TYPEOFINSURANCE IN WVD 9/12/14 9/12/15 EACH OCCURRENCE $ 500 000 BOP9098053 DAMAGE TO RENTED 1 A GENERALUABILITY a cc e MED EXP(Anyone person) $ 15 000 }{ COMMERCIAL GENERAL LIABILITY PERSONAL&ADVINJURY $ 1.000,00C CLAIMS-MADE �OCCUR GENERAL AGGREGATE $ 2 000 00C IPRODUCTS-COMP/OPAGG $ 2 OOO OO( I GEN'LAGGREGATE LIMITAPPLIES PER PRCOMBINED SINGLELIMIT $ 1I X POLICY O- LOC Ea accident AUBODILY INJURY(Per person) $ TOMOBILE LIABILITY I BODILY INJURY(Per accident) $ ,j ANYAUTO SCHEDULED PROPERTY DAMAGE $ ALLOWNED AUTOS Peraccident AUTOS NON-OWNED $ I HIRED AUTOS _AUTOS $ EACH OCCURRENCE UMBRELLALIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS-MADE OTH- WC STATU- DED RETENTION$ 10/11/13 10/11/14 X $ 100'0( WORKERS COMPENSATION WCC500 6538012009 E.L.EACH ACCIDENT B AND EMPLOYERS'LIABILITY Y/N 1OO,O( ANY PROPRIETOR/PARTNER/EXECUTNE —T NIA E.L.DISEASE-EA EMPLOYEE $---500 01 OFFICE RIME BER EXCLUDED? _j E.L.DISEASE-POLICY LIMIT $ (Mandatory in NH) Ifyyes describeunder DES6RIPTION OF OPERATIONS below TIONS/VEHICLES (Attach ACORD 101,Additional Rerrerks Schedule,if more space is requ red) DESCRIPTION OF OPERATIONS 1 LOCA ' ELECTRICAL WORK I CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES'BE CANCELLED BEF THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED r. ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER MA 120 MAIN ST AUTHORIZED REPRESENTATIVE o NORTH ANDOVER, MA 01845 LESLIE HANNON © 1988 2010 A ORD CORPORATION. All rights re: �y ACORD 25(2010105) The ACORD name and logoareregistered marks of ACORD Fax: �i Phone: I