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Home My WebLink AboutMiscellaneous - 142 Kingston Street 1 t II Date..nlolr�............... 't T TOWN OF NORTH ANDOVER 0 x - PERMIT FOR WIRING CHU This certifies that ....................................... has permission to perform .Y'...'� I...................................................... wiring in the building of.... ..................... ............................................................................. -�7--'�c-�North Andover,Mass. at ............................................. Fee.... Lic.No. :.. .................................................................................... ELECTRICAL INSPECTOR Check, a . t & Official USC_011_1Y _! smorwea al fV ae�ae u6e:i1 (fm. - Permit No. C 2'p.'tmed op"Seruice9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) All work to be performed in accordance with the P✓ra;;achu;etis Electnc.al Code Q\'C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAIATIOA9 Date:�rJ 7 j City or gown of: ` An J mf'pf— To the hapecto; of If,"ires'.- By this application the undersigned Rives notice or his or her intention to perform the electrical work described below. Location (Street&Number) KN*iN Owner or Tenant Telephone No. Owner's Address V<z S*&4 Is this permit in conjunction-kith a building permit? <es j No � (Check Appropriate Bo,) Purpose of Building Rtr,'v rq;,�4 qr` Utility Authorization No. Existing Service IQ t' Amps ` O / OLW Volts Overhead ❑ Undgrd d No. of Meters New Service /Ga Amps Id,0 /0jYC)Volts Overhead ❑ Undgrd ✓� �o. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �� ve Feat at. �4Li 1 C 6A-e 6 2 LO `COI+e a&NJ-'o Com tenor,of the fullowina table mm,be waived by the in_c;=r ej Wires. No. of Recessed Luminaires I;;`o. of Cei1.-Susp. (Paddle)Fans N0. cf ictal ITransformer•s KVA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA t No, of Luminaires SFsimmina Pool •4bove ❑ In- ❑ �r'o. o {mergency erg, ring ornd. grnd. IBatter-y Units ` No. of Receptacle Outlets -,No. of Oil Burners "FIRE s L:.4R'YIS INo. of Zones Q No, of'Switches INo. of Gas Burners ,No. of Detection and y Initiating Devices No. of Ranges No_ of Air Cond. Tonsl No. of Alerting Devices heat um -- ' No. of Waste Disposers. P p Number lions ICW ;''No. of Self-Contained Totals: ! `Detecti n/.�lerting Devices ! r ��'i INo. of Dishwashers SpaceiArea Heating kir !Local �� unlci pa! _ _ — Connection _ r luri ..'=erns: 7 IN'o. of Dryers Ideating Appliances KN'Y' i-=- I N'o..of Water K\'t !�_ \o.o;Devices or Eoui�`zl;nt No. of No. o, a —I � I� (Dzta };riving: Heater_ Signs Balsam I No. of Devices or Equivalent No. Hydromassage Bathtubs na: No. of Motors Tota! HP Tei�communicanons Vviri No, of Devices or Equivalent OTHER: �T GO Attach additionsi detail if desired or as required by the inspector of 91irc s Estimated Value of Electrical Work: (When required by municipal policy.) VIork to Start: 9 I Pj Inspections to be requested is accordance with MEC Rule 10, and upon completion. INSURCE COVERAGE: Uniess waived Ly thF, er e o •n ; no pe„nit for the performance of electrical work may issue unless rhAN e licensee provides proof of liability insurance including"apmpleted operation ”coverage or its substantial equivalent. The undersignedcc,:ifies that such co• ge is in force, and has exhibit-_'J proof cfsame to t!e pe: nit issuing office. CHECK ONrE: INSURANCE OND ❑ CT ER ❑ (Specify) I cert y, under the pains and penalties o-_perjury, that the information on t7 ::ca:ion is true and comple(e. FIRM NAME: I CAA mo l LIC. NO.:Aac c Licensee: ;�n to o_, _% o,�C ignature LIC.NO.�Aaddla --ll>F (ifq plicable, enter "exera t"in the licens r.J,r.ber line.) Bus, Tel. No.:Y7� �3c,ak Address: 0- Ayt Q Alt. Tel. ,No.: ' QD *Per M.G.L. c. 14.7, S. 51-61, wo= requires L e_z-Hent of Public Saf ay`S i :cei ,sc: Lic. No, 0W ER'S INSURANCE WAIVER: I:.rn aware i; 7"- Licensee does not hai- !i-'oi!it;insurance coverage -__-._::v _ required by la's,. By my signature below, I hereby waive t is requirement I am th -e Owner/Agent ) ❑ owner ❑o':- a°ent. Signature Telephone No. PFR_4IIT FEE. ACt!DRH CERTIFICATE QF LIA DATI(MMIDDIYYYY) BILITY INSURANCE 09/03/2015 THIS CORTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CBRTIPICATE 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 la an ADDITIONAL INSURED, the po1lCy(Ies)must be endorsed. If SUBROGATION IS WAIVED, sub)ect to the terms and conditions of the policy,certain pollclas may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), PRODUCER Neill&Neill Insurance Agency Inc David.tarry 882 Riverdale Street P"oNa , (413)732.4137 PAX 413 7 West Springfield,MA 01089 e.M IL ac Ne:( ) 31-6629 INSUR9RM AFFORDINO COVERAOS NAIC q INSURED Michael Fareill Electrical INSURER A l State Auto:Insurance Company _. 8TA 9 Applewood Lane INSURER a: Acadla Insurance Co. 31325 Methuen,MA 01844 INSURER O: ENSU E D; INA APR 11, COVERAGES INSURER F: CERTIFICATE NUMBER; REVISION NUMBER: THIS IS"TO CERTIFY T HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINC 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 TYPI OF INSURANCE POLICY NUMBERFXP A GENERAL LIABILITY MM D I M /Ob LIMITS , I 'OMABOP2745517 08/10/2015 0,8/10/201r8 EAC"OCCURRENteV � 1,000,000 I CLAIM$-MAOI: PREMISES(Et OCa�rrE e�nce) ! 50,000 OCCUR MED EXP An one arson 5 - 5,000 PIRSONAL A ADV INJURY S 11000,000 I GeN'L AGGREGATE LIMIT APPLIES PER: - GENGRALAGORSGATS S 2,000,000 POLICY PRLOC PRODUCTS-COMP/OP AGO f 2,OD0,000 AUTOMOBILE LIABILITY S i ANY AUTO I� c EO SCHEDULED BODILY INJURY(Per person) S NON-OWNED BODILY INJURY(Per amident) 6 H:RIC aUT08 AUTOS PROPERTY AMAGE 6 UMBRELLA LIAR OCCUR i EXCESS LIAN CLAIMS-MADE EACH OCCURRINCE I i DEO Af1GRE0AT6 I f B IANDFWORXMRS YNIS'LAMLIT WC-20.20-001461-05 03/20/2015 03/20/ 0 AND eMPl0YeR5'LIABILITY 0TH.+-_-----`•-.-..._-"� ANY PPOPR1ETOR?ARTNER/EXECUTIVe YIN I' OPPICPRIMPMSCR PXCLUD!<D7 N!A E.L.EACH ACCIDSNT 1 100,000 (Mentlstoryln NH) Il yyea des"Ibe OF O E.L.DISEASE.EA EMPLOYEE ! 100,000 OES6RIPTION OF OPERATIONS Calow E.L.DISEASE.,,POLICY LIMIT S 500,000 i I DRECRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,AddltIchal Remarks Schedule,If mon space to rspulred) Foxed to: 978-882-1480 CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESORIBID POLICIES OF CANCELLED BEFORE 1600 Osgood Street,Building 20 TI( -EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVIRED IN Suite 2035 ACCORDANCE TN THE POLICY PROVISION$. North Andover,MA 01845 AUTHORIZED REP 'SE ATN I i • ACORD 26(2010106) The ACID RD name and logo are regls ared marks OfACCRD ORD ORpORA All rights reserved. The Commonwealth of Massachusetts Department of IndustrialAceidents 1 Congress Street, Suite 100 .t" .Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TIE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Orgaaization/Individual): C�1 -P- Address: 2Address: A M-w)(iod i-ane- City/State/Zip: Z Vi , ) YIPhone#: Are y au employer?Check the appropriate box: Type of project e yp p � (required): t.aI am a employer with__employees(full and/or part-time).* 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] I I am a homeowner doing all work myself , 9. ❑Demolition ❑ g y [No workers'comp.insurance required.]` 4. I am a homeowner and will be hiring contractors to conduct all work on m 10 ❑Building addition ❑ g y property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.# 13. Roof repairs 6.❑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 41 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. .f am an employer that is pioviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:---,A&; 'V e t i a6�u Ce A R m c� -i.A(t Policy#or Self-ins.Lie. ( C1 )t C, -� < Expiration Date: Q (; Job Site Address: U 1a, Kk -5;+ 4114 �ity/State/7_ip:.-1(+1 .N Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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 u der the ins and penalties ofperjury that the information provided above is true and correct. Sign re: Fr'JAD PJ Date: Phone.#: Official use only. Do not write in this area,to be completed by city or 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: r A6�9 EkT r F /f f, a' �p�„sg ,�,`fa6a2oienero't,�Sffops. 8r , 00 ,f� 1l Jr ?., Stti v. �t r gfa �M1gN j1?��PY�✓{�5},r� - �q � 41 'y 3 � . �r u � r , Date.................................. NORTH 3r0e,; `°. •�"°G TOWN OF NORTH ANDOVER • p PERMIT FOR WIRING ,SSACHuSEt Thiscertifies that ............................................................................................. has permission to perform ............................................................................... wiringin the building of................................................................................... at............................................................................... .North Andover,Mass. Fee..................... Lic.No.............. ............................................................... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File Office Use Only - 014C �nmmnnWralo of �ia5SaE UJJtt#s Permit No. 2 3 _= +i9epartment of Public —Anfetn Occupancy& Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 siso (leave bank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 ? Ff PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date) 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) Owner or Tenant o Owner's Address 'e11f 9 f Is this permit in conjunction with a building permit: Yes ElNo 5Z" (Check Appropriate Box) Purpose of Building YLJ� Utility Authorization No. nl2fLo Existing Service -70 Amps 1,�_Idl 2-q-0.volts Overhead U Undgrnd ❑ No. of Meters _ New Service Amps ice'— is Overhead Unclgrncl -n n Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Transformers Total No. of Lighting Outlets No. of Hot Tubs KVA No. of Lighting Fixtures I Swimming Pool Above In- grnd. ❑ grind. ❑ I Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners I Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges I 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 I Space/Area Heating KW Detection/Sounding Devices Local Municipal ❑Other No. of Dryers I Heating Devices KW ❑ Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP Shf Q OTHER: oo 1lL" �' s O �h s £ J INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy inclu leted Operations Coverage or its substantial equivalent. YES NO 1 i . YES,__R_' NO = If you have checked YES. please indicate the ype of coverage by have submitted vali proof of same to the Oft c� Y checking thea p priate box. J f ,37y_5'r INSURANCE BOND - OTHER _ (Please Specify) � /�r (1 P ��tfu !L (Expiration Date) Estimated Value of ecttical Work S Work to Start , ?S Inspection Date Requested: Rough , J Final Signed under the Penalties of perjury: LIC. NO. FIRM NAME LIC. NO. Cac�` p3 Licensee hn K/ us s � SignaureT yf Bus. Tel. No. s6g Q�7 3 Address SfrQ��" ✓"N Ctc ` /r!/�SS Alt. Tel. No. u 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. Ow er Agent (Please check one) Telephone No. PERMIT FEE S f (Signature of Owner or Agent) x•5565