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Home My WebLink AboutMiscellaneous - 140 Kingston Street . r Date...��. ..� OF NonrH,� TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING ' SS�cHus� Thiscertifies that ................................�.......................................................................................... �. has permission to perform .. ..�U��.. .�..... ..! .. ......................................... wiring in the building of........ .! .. '. -...................................::................................. at ................t....`Q........ :.... .. .........,-,z............. ..... ,North Andover,Mass. Fee..3........1.........Lic.No ........... .... . ..................................................................................... ELECTRICAL INSPECTOR Check# 12676.,-( m '' Cm.mon:aeaR o f f/la_49achuie�5 Official Use Only Permit No. � C �!JcPartme�x�o� ire Jeruices , Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) I APPUCA [ON FOR P ERMUT TC, PERFORM ELECT CAL WOR All work to be performed in accordance with the Massachusetts Electrical Code(,1vlEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE XLL INFORMATION) Date:- City Date:City or Town of: & 4oye f To the h: pec o,- of fflires: By this application the undersigned gives notice of his or her intention to perfom; the electrical work described below. Location (Street& Number) 14 0 V1 1 11 cj+o A Owner or Tenant h' � �V Telephoneo."7� (lad mer,s ddre_ N � Is this permit in conjunction with a building permit? Ves l ] No (Check appropriate Bo.) Purpose of Building '15�,JIMA( Ikk Utility Authorization No. Existing;Service� .Amps )do /d�-Volts Overhead ❑ Undgrd No. of Meters w New Service 100Amps a p / Iyb Volts Overhead ❑ Undgrd FX No. of Meters l Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 5-4,11,(91+4t t C 4At( oA ctb 6( ge VF W o-q W(A S ia Met C o Call eo f O f WtP,f Completion of the following table mcn,be waived by the lrs_,)eC;or of fflires. Vial i No, of Recessed T�umrnatres it o. of Ceil.-Susp. (Paddle)Fans No, of ns Transformers hV.A No. of Luminaire Outlets No. of Hot Tubs (Generators KVA No, of Luminaires ISwimmina Pool Above In- I '0. o mergency_rRhung grnd. arnd. (Battery Units _ No.of Receptacle Outlets No. of Oil Burners �FIIZIL:1RrIS INo. of�Zones No, of Switches INo. of Gas Burners €No. of Detection and i Initiating Devices I No. of Ranges No. of Air Cond. Total 'No. of.Alerting Devices Tons 5 No. of Waste Disposers. Heat Pump Number 'Pons KW 11N'o, of Self-Contained Totals: I •Detection/A.lerting Devices _t No. of Dishwashers Space/Area Heating k-VV Local IJ r"unicipal I� rj_� r E _ Connection F jNo. ofDryers Heating Appliances KW iearl Svtems:r – No.of D'.evices or Equivalent No.,of WateI. i No. of No. of _�--- _ KW Data 'NVii Mg: Heaters Suns Ballasts � No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors 'Total HPtelecommunications Wiring: I _No. of Devices or Equivalent OTHER: Attach additional detail ii desired, aa•a.r requires'by the Inspector of(Tires. Estimated Value o Electrical Mork: ! (GVhen required by municipal policy.) 'or!; to Start: Inspections to be requested in accordance with MEC Rule 10, a:]d upon completion. INSUR,kiNTCE COVERAGE: Unless waived by t:e o ner, no permit for the performance of electrical work may issue unle_s the iic•ensee urc,-ides proofof liability insurance incluir,g"completed operation"coverage or its substantial equivalent. The ui?derir :]3d.Gt,r-il eS that such co v� ge is in force; and has yxhibiie` -Qoi Or Same to t`!e peri7lit iSSi]lno office. CHECK ONE: ITrSURANCE 9 BOND ❑ OVER ❑ (Speci=.:) I certy, under the pal s and penalties•of%erjury, that lite informaticr: o;: :: : _� Iic tion is true and complete, FIRM NAME: �jNa PI A r �af l .. LIC. NO.: � Licensee: � TCv�IP- Si-nature_ LIC.N0.;�n� (If app/icablz, r xe t"ir:the license number line;) Bus. Tel, N'o.: �j- a .�dot Address: � e�aGd l.lM[� / 1 ,y-tn 'No Q� ��(IQ *Per M.G.L. c— 147, s. 57-61, securit work e uire�-i;=_,z Alt, Tel. N'o.:��fi��`S'Y�1��O Y q `r nt of Public Safety r ; tense: Lic. No, OWNER'S INSURA-NCE WAIVER: I am aware tt:.at r'.�?e Licensee does not leve 7- lia i1i � insurance coverag required by la•,,, By my si ature below, 11]ereby wai,_ : :s requirement. I am t:-:e(_';ec'.•;one) ❑ owner ❑ c;y_;e. ,ant. Owner/Agent Signature Tele; hone No. PERMIT FEE: S The Commonwealth o f Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 . www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. Alicant Information TO BE TILED WITH THE PERMITTING AUTHORITY. Please Print Le ibl Name (Business/Organization/Individual): t Address:_ ,A an e— City/State/Zip: ) .y`)Phone Are yqp au employer?Check the appropriate box: fL�Jy% F7. F1 project(required): 1. I am a employer with employees(full and/or part-time).* ew construction 2.❑I am a sole proprietor or partnership and have no employees working for me inany capacity.[No workers'comp.insurance required.] emodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t emolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mI will 10 0 Building addition ensure that all contractors either have workers'compensation insurance orae solproperty. 11.( Electrical repairs or additions proprietors with no employees. 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs of additions These sub-contractors have employees and have workers'comp.insurance.# 13.[j Roof repairs 6.❑We are a corporation and its officers have exercised their light of exemption per MGL c. 14.❑Other 152, 1(4),and we have n§ o em to ees.�o workers'coli r.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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 number. I am an employer that is providing workers'compensation insurance for lily employees. Below is thepolicy and job site information. Insurance Company Name: ffe- gel" 11 —'.�S{J[aij cF A q m cc p c t Policy#or Self-ins.Lie. C U.-0 (y -I Expiration Date: Q`y Job Site Address:_9 • —� 'VGo 4L A tirlitCity/State/Zip:,/_V& f )6 Attach a copy of the workers compensation policy declaration pag�(showing the policy number and expiration date), v Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the 'ns and penalties of perjury that the information provided above is true and correct. Si nature: J Date: Phone#: C /– ` A 3 -- 3 o a [[Official use only. Do not write in this area,to be completed by city or town official. ty or Town: Permit/License# uing Authority(circle one): 1.Board of Health 2.Building Department 3.Ci /Town Clerk rk 4.Electrical Inspector 5.Plumbing 6.Other P g Inspector Contact Person: Phone#: u0:00lvC, a nsurance Agency (t-AX)14137316629 P.00'1/001 �`'CCIIIR" CERTIFICATE OF LIABILITY INSQIRANC`E DATE(MM/ppryyyyl E,REPRE�SENTA71VE CATF IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONF1 15 ERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS DOES NOT AFFIRMATIVELY OR NF,GATIVI;LY AMEND,.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE OF INSURANCE DOES NOT CONSTIYUYE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED OR PRODUCER,AND THE CERTIFICATE HOLDER. RTANT: It the the terms and conditioIo ni f oth holder la an ADDITIONAL INSU ,cartsln policies RED, the pollcy(I.$) must 01 endorsed, I(9UBROGA710N IS WAIVFp,aub)ect to cenlflcate holder In Ilsu o}ouch ns o!the policymay require an endor$OmenL A statement on this Certificate does not confer rights to the ondoraemenf(a). NRODUCER Neill&Neill Insurance Agency Inc . David tarry 862 Riverdale Street NHONa (413)732.4137 NqX West Springfield,MAO 1080 a-M I° -- ____ _�_• (413)731-6629 anoae sI IN9URGR S AFFORDING COV6RAG5 INSURED MlCheei Ferelll EIBCtrIC81 INEURaR A t Slate Auto:lnaurance Gompany -Nalc a 9 Applewood Lane STA INSURER a: Acadia insurance Co, _j 31325 Methuen,MA 01844 INSURER c: JNOU.�D; COVERAGES CERTIFICATE NUMBER: INSURER F: THIS 1S 1'O CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR REVISION NE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIEIEO NERL IN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SNOWN MAY RAVE SEEN R[OU,OL f I PAID CLAIMS. INSR TYI•!Of INSURANCE AGENERAL LIABILITY POLICY NUMSER M t. I M IDG OMITS COMMERCIAL GENERAL LIABILITY BOP2745517 06/10/2015 08/10/2016, r EACUOCCURAZNtE S 1,000,000 CLAIM$.MADe 171 OCCUR P MI rr nc! S 50,000 MEDEXP An one arson 5 5,000 PERSONAL A ADV INJURY S 1.000,000 I GCN'LAGGREGATE LIMIT APPLIES PER: GENERALAGOREOATS S 2,000,000 POLICY PR - LOC PRODUCTS-COMP/Oa AGO b 2,000,000 � I AUTOMOBILE LIABIUTY S ANYALITO - ALL OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS AUTOS ,;RED AUT08 NON-OWNED BODILY INJURY(Per ealdem) S AUTOb PROPERTY AM CE LPSnU 5 UMBRELLA LIAA OCCUR _ S)I LJAB CLAIMS-MADE EACH OCCURRENCE I S DEO �AOOREOAT'e IS B WORXLIRS COMPENSATION - S AND eMPLovtA8'UARIUTY WC-20.20.001461-05 03/20/2015 03120! 0 T,'—'^—I-O--T—H,- ANYPROPRIETOR?ARTNER/EXECUTIVE YIN OFFICER/MEMSERFXCLUDID7 a jNIA1 f-� (Mandatory in NN) C,L.EACHACCIDENT 6 100,000 II ySS Ceanlbe untlar EL.DISEASE•E:.EMPLOYEE ! _ _ 1 DE9L�RIPTION OF OPERATIONS EA.. 100.000 E.1_OIS'e 5.PO:ICY LIMIT S 500,000 I . DRSCRIPTION OF OP(RATIONS 1 LOCATIONS/VEHICLES (gttaxh ACORO 101,Ad01UonH Remarks Schedule,I/mon space sce fa npulrvdl Faxed to: 978-682.1480 CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED R EFORI! 1600 Osgood Street,Bulfding 20 TH EXPIRATION DATE THEREOP; .NOTICE WILL BE DELIVERED IN Suite 2035 ACCORDANCE TH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REP SE ATNg i ACORD 26(2010/06) ®1988-2010 ACORD, ORPORA All rights reserved, The ACORD name and 1090 are regls eyed marks of ACORD I n _.R ................ .. ... �•k,' C + � Pfig WI t f , }, ,o, }{� I I f � ' Al Date. . . . .... ... .. .. . . .. . . ,,ORTH Of 4,0 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACHUS This certifies that . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . ... .... .... . . . . . . . . . . . . . . . in the buildings of:. . ... . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . .I. . . . ... I. . . . . . . . . . . . North Andover, Mass. 'Fee. . . . . . . . . Lic. No.. . . . . . . . . . . . . . . . .. .F .. . . . . . . . . . GASIN$PtC-rOR Check MASSACHUSETTS UNH'ORM APPLICATON FOR PERMIT TO DO GAS/FITTING (Type or print) Date D 2— NORTH ANDOVER,MASSACHUSETTS Building Locations 1"1 ('Vi 4-S `V V\ -S�� - _ Permit f Amount$ 0I l �C f e �<rc cy1 w e- -1 Owner's Name J-00-AA e s 6 CA e_f New❑ Renovation ❑ Replacement Ef Plans Submitted ❑ c SUB-BASEMENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) p C one: Certificate Installing Company " Name W t I f1�^^ r>vro r(Cc VI Li Corp. Address I " f�'� 'G S�F� Aun ❑ Partner. Business Telephone ffFinn/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked M please indicate the type coverage by checking the appropriate box. 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: `Y Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installati perf Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S e hapter 142 of the General Laws. By: Signature of Li ed P ber Or Gas Fitter Title VGas umber I 'SrpCity/Town Fitter icense um r aster APPROVED(OFFICE USE ONLY) ❑ Journeyman