HomeMy WebLinkAboutMiscellaneous - 136 Kingston Street �i
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Date..Lol 1A,-,
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NORTIy
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that ...
......... ....;
........................................... ..................................................................
has permission to perform ........ .&A0.......................;.....................
F. wiring in the building of........ .......................................................................
at ....... North Andover,Mass.
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Fee....5:�................Lic. No. G ..................................................................................
ELECTRICAL INSPECTOR
Check#
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Common!4 eaR 0/�VaJ.JaC4L1Je_ffi Official Use fly
PciTnit No.
Seruicg9
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Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Occupancy
1/071
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APPUCAT[110-N FOR PERPvciff To PERF0r--,2M ELECTRICALAfORK
All work to be performed in accordance with t"' I Code(MEC), 527 CMR 12.00
(P'F PRINT D R
IATIN 1MV, OR 7�'PE-,I�L. �N'FORAIM TIOA) D
City or Town of': ((— TO :he �'c i:�?- qV_FYi I'CS.,
By this application the undersigned Bi-\'Cs noice of his or her intentiontop-.rf0Tn-j described bt-kr,.
Location (Street & Number)
Owner or-Tenant
No. 3 S
I u L
this Pernlit ill conjunct!on vvith 2 Luildimz perinit? 1,10 heck -i ppropriate Bo.,,
Purpose of Building U
P5 -VI Unilit-y Authorization No.
Existing Service )GV :imps
dr,_L.Z— Volts Overhead Unclard Nlo. of Meters
New Sevvice :imps o
"(0 Volts Overhead L
_J Lindard Leters:N o. o f Mi
Number ofFeeder's and Ampacity
Location and Nature of Proposed Electrical Work:
br U-4-t AIQ t
_j
71 waw-ed by.,�.e
compi�7,-:
t'h. ofRecessed Lum,-1jj2:Lr._-s 0. Of Ced.-Susp. (Fadcdi�_.) i_Tr2nsforiner's
A
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or' e—
s
e
'2'r
N No. of Luminaire Outlets No. of Hot Tubs
o T_ 1 Generators
No. of Luminaires A.bov- n _N oof L�m ee Fgre_,nc-
4 iswirilming Pool
Receptacle
Outlets
grnd.c 'r-nd. I B a tten, I�n its
No.
cpt
o. of Receptacle outlets 0 (-.,f Oil Burners
F1 17LE A L A.I�A I IN0. of Zones
OfS Switches
—0
• of 0 e t L c—no 11 and —
initiatirw Devices
INH. 0f Ranges Nc. of Air Cond. Total
N 0
Tons 1 - C�-fAlerting Devices
N,0 Mat I urnp N,0. G.
Of Waste Disposers .......... _M�E ff—C 5-11 t a i rT—ed
Deviccs
Icip a l,
No. of Disfiv),as ers Spacci-/A.rea Hearing KW
IS 11 lers c-
Corinecdon
l
of Dryers e e rs Heating Appliances KW S
ate I*--
i 0. of W 0. i C tis or E i% n t
1110
K�,N` Of
Signs
evices or
No. Hydromazsarye Bathtubs
!
IN 0, of M o to rs To:2! F1 P
I --cOrnmunications
f
No. o D evicCS Of- L
LOTHER:
or as requi,-2.-�by the
Esmmated Value of*ElrctT'cal r=P ("f T i.!
(Wbc�-equired by mumciiEl policy.)
1: to Start: �_75 to With NIEC Pule 10, ai-2d mpoTi co:_m,"Ielion.
INSUR-k-NINCIE COVEP_1GE: Unless wz;vtd
`e --o pt!T-mitt _fD!Tnanct�of el-
for the Per ` I _ctrical v.,oTk may issue
Doofoflialbil: ins --ane-,
e a t ion COUP.?doe oT its s"
...... `-•C' -e-71T!P ibstantial equivalcr
't such �"3vz-, aae M f,-T_ E,
C C K'CN E: DI?-.k N C E R
V BONIT- ER F—I (sp`-
10 1.111 0!.
t 0!Dctjun" and cc)mp leve.
unser-�ze pairs and
On i 0-1 C,
ice,'i se e: (V\ CA�\, A , F&(-e t Signatureture
L
LTC. NO
(j exempt in -he license I
Address: •S ernQ, m4n, Bus. Tel. No..
�Per 1-472 S. 57-6!,security 7)_7��_ A I t. Tel. No
,,_ut of publ,
IC St
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0`�V.NE R S I N S 111 RA.'\1 C E 'k VA I V R R.- I -,varc Licensee-does nor h',
�- 7 . :�.—ill'y inSLITEITICCC
requited By my siE-rure below, T
7:�.!.Z-��qUJFCincnt. I a 171 7'r.-
7
Owner/Agent Ej o v,,n c.
si-nature nrl-No. I)EIL111111,FEE., S
The Commonwealth of Massachusetts
Department ofLzdustrialAceidents
T. :.t o
1 C0119ress Street, Suite.100
.Boston, 31A 021-74-2017
www.mass.gov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/P
Applicant Information hunbers.
TO BE RILED WITH THE PERNHTTING AUTHORITY.
Naine (Business/Orgatlization/Individual): ` }-� Please Print Le ibl
Address: 1 G't?(l — —
C1 t_
City/State/Zip: inn t�1� > --
[2.E]
re yqp an employer?Check the appropriate box: —
am a employer with Type of project(required):_employees(full and/orpart-time).I am a sole proprietor or partnership and have no employees working 7. ❑New construction
an capacity,of , for me u,
Y [No workers'comp.insurance required.] 4. 0 Remodeling
3.L[I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will TOE]Building addition
ensure that all contractors either have workers'compensation insurance or are sole l
proprietors with no employees. [ Electrical repairs or additions
5.[�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.t 13.[j Roof repairs
6.E]We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'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 are doing all work and then hire outside contractors must submit a new affidavit 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 their workers'comp.policy nirnber.
I anz an employer that is providing workersCompensation illsurance.for illy elllployeeS. .73eloty is the polio and job site
information.
Insurance Company Name:
�ns 1
Policy 4 or Self-ins.Lic.#: 67 C1 I `) -----
Expiration Date: C, }
Job Site Address:_ _, o
n� ���` �� /State/7_,i
Attach a copy of the workers' com ensation policy declaration pace(showing the policy number and expiration date).
Failure to secure coverage as required under MGI,c. 152, §25A is a criminal violation punishable by a-Fine up to 51,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER.and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations
coverage verification. y mations Ofthe DIA for insurance
I do hereby certify und r the pa' sand penalties of pezjuiy that the it formation provided above is true and correct.
Signature:
7 Date:
Phone#: D
Official use Only. Do not write in this area,to be completed by city or towTl official.
City or Town: I'ermit/L icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector >.Plumbing Inspector
6.Other
Contact Person:
-- --- Phone#:
07/01/2015 09i21Neil & Neil Insurance Agency (FAX)14137316629 P,001/001
Ac CERTIFICATE OF LIABILITY]NSURANCE °A07101/20'5`'
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE;HOLDER,
IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the pellay(les)Met be endorsed, If SUBROGATION 15 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In Ileu of such endorsement e.
PRODUCER Neill&Neill Insurance Agency Inc PNAO MI,IINa David Jerry
662 Riverdale Street (413)73211137 (413)731-8628
West Springfield,MA 01088 AODRe �'
' IN R'- APPOROINIi C V M MAIC N
IN&OFRALSIataAuto Insurance Company STA
INSURED Michael Fareiil Electrical . Acadia Insurance Ce; 31326
8 Applewood lane INJURER
Methuen,MA 01844
au ea�i —
INSURER P i
COVERAGE$ 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.
/NSR AVU6ME OF INSURANCE POLICY NUMaER N 1 bt LIMITS
A GENERAL LIABILITY SOP2745517 08110/2015 08/10/2018 FACH OCCURRENCE s 1,000,000
COMMERCIAL GENERAL LIABILITY ,gccurrenalS 60,000
CLAIMS-MADE a OCCUR MLD EXP(Any rine anon a 5,000
PERSONAL AADVINJURY $ 1,000,000
6ENERALAGGREOATE $ 2.000,000
GEN'LAIGGRPOATELIMIT APPLIES PER: PRODUCTS-COMWOPAGO S 2,000.000
POLICY IPA LOC _
AUTOMOBILQ LIABILITYdgntl
ANY AUTO BODILY INJURY(Pet pmon) S
AUTOS ED AUTOSULtiO
BODILY INJURY(Por acddenl) ;
S
HIRFDAUTOS NON-OWNED
AMT03
UMBRELLA UABOv^^CUR EACH
OCCURRENCE b
RXCREIIUAa HCLAIMS-MADS .AO P_ROATB s
090 WliNTION S I I $
(3 0ORKERS COMPENSATION WC-20-20.001481-05 03120/20115 03/20/2015 A u• JH.
AND EMPLOYERS'LIARTUTY _
ANY PAOPItI[TpRIPARTN[Rhrr!CUYIVEN 1 A 5.t.,EACH ACCIDENT S 100,000
OFFICERIMIMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE S 100,000
(f no daauibeunder
E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach AGORO 101,Additional ReMarka schedule,H Moro&pace IN required)
Faxed to: 878.682-1480
- 1
CERTIFICATE HOLDER ! CANCELLATION
SHOU4D ANY OF THG ABOVE 0680RtpEO POLICISS BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1800 Osgood Street,Building 20 ACCORDANCE WI E POLICY PROVISIONS,
Suite 2035
North Andover,MA 01845 AUTHORIZED REPRESTA 9 ,r > .'
M: r
•
Q 1966.2010 ACORD C(MPORATIOR,4A rights reserved.
ACORD 23(2010108) The ACORD name and logo are registered marks of ACORD
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