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Home My WebLink AboutMiscellaneous - 144 Kingston Street I Date..j..11.. . �............ NOR OF71y 3a; �o� TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING �ss�cHuss . This certifies that ......... .........t � `........................................................................................ has permission to perform ....Y. >t " - �( .... ......................................................... wiring in the building of.......... P °�Q ............................................ .......................................... at ............1.0.`1.............?' .i "......!.. !............................,North Andover,Mass. Fee....,, -1)................Lic.No.,.62-9.2".................................................................................... ELECTRICAL INSPECTOR Check# � s -s M f /� PD/ (//�j� / C� mmorwea& of/C/a4jacku-jedl Official Use Only cc�� Permit Into. r 2eparlmenl ofJ ire Service9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS LRev. 1/07] (leave blank) APPUGAT` Q,N FOR PERMHT TO PERFORM ELECT CAL VNOR All work to be performed in accordance with the iylassachusetis Electrical Code vIEC),527 CMR 12.00 ("LEASE PRINT IN INK OR^T�Y,PE ALL INF ORMA TION) Date: R f'R Is City or Town of: k& V e r:= f lir �1/�, G �� To tr�� I;a�..ct;�:-� l�tt es: By this application the undersigned gives notice of his or her intention to perform the electrical •,vork described below. Location (Street&Number) 14%4 K',,,nt,sie^ 54- Alco), Amwe Owner orTenant g��{ '`Q` L[P,{V,P/ Mme/ ( /�_rM� Telephone No. (lamnr's Address _ �U�L I��/i�LS-J n �� L• {/Q+V� i'VI�UICf�t r Is this permit in conjunction with a building permit? es ❑ Into ❑✓r (Check Appropriate Boz) Purpose of BuildingV R2 s � J"I A,L Utility Authorization No. Ezisdna:Service 10j .Amps ) / I(j Volts Overhead ❑ Undgrd ❑� No. of Meters (_ New Service iUa Amps WG 1,=)q0 Volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: RP-Move- Fe (� \ Com lF.tivn oft e fallowing taoie mcn,be waived by the ins�ecto,- j Wires. F• • No. of To•ta1 No, of Recessed Luminaires „o. of Ceil.-Susp. (caddie)FansTransformers I' LVA No. of Luminaire Outlets Ildo. of Hot TubsGenerators KVA Above In- �'o. o +meraencv .1g, ung No, of Luminaires S-wimmina Pool arnd. ❑ grad. ❑ (Battery Units No.of Receptacle Outlets INo. of Oil Burners `FIRI1 ALAR-MS INo. of Zones No, of Switches No, of Gas Burners rNo. of Detection and Initiating Devices 1 No. of Ranges No. of Air Cond. Tonsl iNo. of Alerting Devices No. of Waste Disposers Hent Pump Number Tons KW kNo, Of.-Self-Contained r Totals: I Detectioru'.Aler•tina Devices ! �\ No. of Dishwashers Space/A.rea Heating k-W kI oc?1 I ;; .`.'Iun!cipal — C.J.r l Q� Connection c INo. of Dryers Heating.-Ip pliancesK\V I`_='- tt 'sterns:' No o, Devices or Eau,✓alent__� iNo..of«rater• No. of No. of Heaters R`A, Jatz I Signs Ballasts �^ - No. of Devices or `gu;valent No. Hydromassage Bathtubs INo. of Motors Tota! HP i,L iecom: ,urrcahons r ;r!ng; No.of Devices or Eouivalent OTHER: Dd Attach additional detail if desired or as required by the inspector of ff'ires. Estimated Value of Electrical Work: W W I (Nhen required by municipal policy.) \Fork to Start; ( 1 S Inspections to be requested in accordance with MEC Rule 10, and upon completion. r'NSURANCE COVERAGE: Uniess waived by the of=,Me.r,no permit for the performance of electrical work may issue u:!i.e.; rile licensee provies proof of liability insurance includin_"ao:r_�Pl�t�d operation"coverage or its substantial equivalent. :,n ersi�ned ct if es that such co-�� age is n force, and has exhe;_ - o' ibitT :a nn. to the D2 rait issuing office. CHECK ONI : TNSUF?NCE [BOND ❑ T H - �0 SER ❑ (Spec;.;:j I certify, under the pains and penalties of perjury, that ire information c:: c: :__D,tiscrio;t True and complete, FIRM NAME: _ 1 • a sett LIC. NO.:;�aag_ Licensee: ` SignatZure LIC.NO.A),c e (If applicable, enter ",.zem,Pt' :he license nwrber line.l `( l��i us. Tel. l�'0.. �'�U — 3 0�1,l Address: 04(�1�S� t1o� LC'- 1 ��T1,� Q„5,�� . SS It. Tel. No.: *Per M.G.L. c. 147: s. 57-61, security wort:requires De..= ment of Public Safcry"S �.cet se Lic. No, _ OWNER'S INSURANCE WAIVERS I a-- aware t1h_ :e Licensee does notiia' ilii;insurance coves_- required by law. By my signature below, I-reby w.ai-,:.t`s requirement. I am t-,e .c i; e e) ❑ owner Owner/Agent Signature Telephone No. PT-'1LWT FF_:I-: S �� The Commonwealth of Massach usetts G Department of.IndustrialAccidents = 1 Congress Street, Suite 100 .Boston,.MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib� Name (Business/Organization/Individual):_M"CV-41-0 Address: >� a N{_Woo� Lan e— City/State/Zip: fy,R:- \AL-tn S� ) Y!Phone#: - 4d 031 Are yqy an employer?Check the appropriate box. - I Type of project(required): 1. I 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 any capacity.[No workers'comp.insurance required.] 8. Remodeling 3. I am a homeowner doing all work myself 9. ❑Demolition ❑ g y [No workers'comp.insurance required.]t 4. 1 I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will 1.0 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[Electrical repairs or additions proprietors with no employees. 12. 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.D.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#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 my employees. Below is thepolicy and job site information. Insurance Company Name: ill $' /Y e l[ ,!D 5U CaA c e A c Policy#or Self-ins.Lic.#: C ' (} (y Ea i Expiration Date: Job Site Address: 4q t rr c,+ City/State/Zip:_A0 �Y�f �A, y Attach a copy of the workers' colnpensation 1{6licy 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. Ido hereby eertif nder th p 'nsd pen lties ofpezjuzy tlzat the if formation provided above is true and correct. 0 6 Si nature: Date: �7 Phone 0 A Official use only. Do not write in this area,to be cofnpleted 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: y J `' CERTIFICATE F LIABILITY INSURANCE pA09l0312015) THI8 CCR7IFICATE 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 COVERAGP AFFORDFD 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 CeRIflCete holder la an ADDITIONAL INSURED, tho poticy(Iss)must be andoreed, If SUBROGATION 18 WAIVEp,aub)ect to the terms and condltlons pf tho policy,csrtaln pollcles may require en endOreomenL A etetement on th(e certlflcata dose not confor rlghta t°t t celtiflcate holder In Ilau of auch endoraement(a). PRODUCER Neill&Nelil Insurance Agency Inc David Jerry 882 RlverdBle Street PH°Ne (413)732.4137 FAx West Springt3eld,MA 01089 e.M IL - ac Ne;(413)731-6629 AD 10 61 _ IN SURgRtAl AFFOROINO COVfiRAOIi NAIC 0 INSUKLO Michael FerelII Electrical INSUARRAl State Auto:Inaurance Company ~ STA 9 Applewood Lane INSURRR a: Acadia Insurance Cn, 31325 Methuen,MA 01844 INSURER C: NSU E D; INE RPR E i COVERAGESINSURERF: CERTIFICATE NUMBER; THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEREVISION UFOR�R[POLICY PERIOD INDICATED. NOTWTHSTANDING 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 TYF1 OF INSURANCE A OENERAL LIABILITY POLICY NUMIIR M D___ I Ma/Op BOP2745517 06/10!2015 08/10/2016 LIMITS COMMERCIAL GENERAL LIABILITYr EACG OCCURRENCE f 1,000,000 CLAIMS-MADE OCCUR �P—REM16Ea(E10 rc�nce) f_ 50,000 I MED EXP(AnY one I/ripn+ s 5,000 PERSONAL A ADV INJURY f t,QQ0,000 --------------- I GEN'LAGGREGATEUMITAPPLIESPER: GENERAL AGGREGATE S 2,000,0DO POLICY PR r LOC PRODUCTS-COMP/OPAGD f 2,000,000 AUTOMOBILE LIABIUTY i f ANY AUTO -•••�» uuoroli R8[E'n ALL OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS AUTOS H;RED AUT08 NON-OWNED BODILY INJUORY(Per g Wdenl) 6 AUTOS 1�OPERTY#90911SAMAGE 6 UMBRELLA LIAR OCCUR f eXCISI LIAN CLAJMS-MADP EACH OCCURRENCE I f DEO A0(jRE0AT6 If I3 wORRER1 COMPENSATION AND EMPLOveaB'UABIUTY WC-20.20-001461-0S D3l2D/2015 03/20! p OT",I' —� -- ANYPROPRIETOR/PARTNER/EXECUTIVE YIN l' OFFICER/MEMBER EXCLUDED? a Nl A (Mentletoryln NH) B.L.EACHACCID!NT 6 100,000 !r yee deerflDe untler E.L.DISEASE.EA EMPLOYEE f 1 DE9L�RIPTIONOFOPERATIONebelpw 00,000 Er L•21I 9fi.POLICY LIMIT S 500,000 � I DRECRIP TION DE OPIRATIONS/LOCATIONS/VEHICLES(Alleoh ACORO 101,AtldlUonel Remerke Schedule,Ir mon epees(e nputryd) Fexed to: 978-682-1480 CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE 1600 Osgood Street, Building 20 TH -EXPIRATION DATE THEREOF; .NOTICE WILL BE DELIVERED IN Suits 2035 ACCORDANCE TH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REP '9H AT'Nj i t ACORD 26(2010106) (01988-2010 ACORD, ORPORA The ACORD name and logo are regls Bred marks Ot�ACORD All rights reserved, I I • � �.. a � .a%� .•��bf�uoa so��rs.Yo.&f�?ope ,,... na , LSu4 �Tss,�1N � �^tom �'a3•�„, 1 9D r I > i � C {