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Date. k),1 .........................
OF NOPTA#
03?; ,; ;•. oom TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
'38�CMU5�S
This certifies that ...............�C. e�n�......-T�Ye..' ............................:.........................
has permission to perform .. �d.......
. ..............................................C .......
wiringin the building of.............. ...........................................................................
at ................. ..... '.4.+. .... 4 v..:.........�.... ... P. North Andover,Mass.
Fee...... .............Lic.N2 o.
G ZGIZ..............................'.................................................
ELECTRICAL INSPECTOR
Check# j
2x
ol Ma,�iac4tje!-L OfficialUse 0111Y
PerTnit NO. qj
2eparlrnend"I ire—�"Vicej
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS -Rev. 1/071
(leave blank)
APPUCAT[ON FOR PER rit,t[T
Ll TO PERFORNI ELECTMICAL WORK
All work io be PrFflorrned in accordanCC Will) Cod:NEC), 527 CJ`vfR 12.00
IPLF 'ORAIA 7701\1) -q to:ASE INT IN 1mr, OR 7'YPE,J�Lj, T?[,rORA
City Or T,OA,n of:
1�f'� TO the
By this application the undersigned
::once' Of his or her intention to perform :l't CleciTical described b,-10*1Y.
Location (Street& Number) Ll I 4 4u)
Owner*or Tenant
Fer,S l A S A N
! Ad d". Wall
Is this permit in conjurictio-1 -0)'Ith 2 b1lildMiT permit? Jiqo (Check'-i'ppropriate Bo.,,)
Purpose of Building T idlity Authorization No,
Existing Service Amps Volts Overhead Undard
Aut- L"00- -No. of
New Service _L06 Amps Ido / ]---qb Volts 0verh2ad Jnd-rd No. of IN/1-eters t
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: VI
C)V
C)
11,1o. of Recessed T:urj�jja:---
No. of Ced-Susp. (Padc�i--.) Farls o' of
I TI-2 nsformers
No. of Luminaire Outlets
No. of Hot Tubs ors
Gen-r-qt
N
'o
0
N-0
No, of 1swiniming Pool '-kbo�- 'r-nd. I Batten, Units
I �Irrid.
No. of Receptacle Outlets No. of Oil Burners F I ME �A L A R-�IS
N10. of Zones
No,
of Switches No. of Gas Burners ,:�o. of Defection an
lnidptin�, Devices
N 0 Total
o. of Ranves of Air Cond.
N r. Tons cl Altrdn- Devices
N'o. of Waste Disposers 1-1 C'a t Purr,p
Contained
To .1f ler-fing Device-
IN"o. of Dishwashers Space/A.r-----2 Heating KW 6 in—1c i P 2
L-c—d c
0' of Connection 9-
D i"
N'c. of Dryers Heating Appliances
f t r
tej. No. of —--------—S—.0. C.—i
ea t
H e a t t I-s KNV 2-:
SiEns I;allasa s;
f D E v i c c s or E,'� n t
'o. Hydrorna�spae Bathtubs E C cj-,,rn--i i i-c 2--�i-on s—t,i
INo. of Motors ToE�.! HP
"6evice's or, Eguk4lent
No. of
OT H ER:
Es�irrated Value ofE-:j1cct-' require,^ ecior of Wi,-
cal jj Tequ!--d by murjici-,)j..j Dolicy.)
to Stan: to in--�,--Coidance with �N2EC '
' Rule 10, Pn-d UD071 COMpItijorl.
INISUR.-kiNICIE COVERAGE: Ll less
Do L)tr-. it for the performance of z!tcfrical v-!Ork may issue L,-11�-z
r- s D-'Oof Of 112'-;i:T .itC0
Or its substantial equ:'Valent' 7.�I-
LTT;,�Q I.II f,)T TI
such C'3V W -7 :R;71C
tlt D71 �SSIIMR OTTIC��.
CHECK FE-A F-1 (Su
)NE: INSURANCE F-t-e BON".)
--j
-y"JV1 h pains and rEn 16
under—e - 'I oerju
a les U! 0"'tr '5
Fri,i�f NAA11E.: (AA&- IC. N A) 0
C
MW
-t-, ne. UC. NO.: r,d
o 0.)
Address:/
d r�e s's: V_� B u s. Tel, No.:
Alt. Tel. No..-
4Per tV1 C.L. 57-61,security Wc-,-�
ire: -11t of Public S:.::..
MNVNEPZ'S INSURANCE.WAIVER.- I Licensee does nor h'— 2
inSL1--?n(.'C C�DNI=ra�
required by B -ture below, 2�7�by vv� quircrne.D
3, y s j grit
Owner/.Agent --• c) El O--'vnc-'
nri e.No. T FEL�.- S
The Commonwealth of Massachusetts
Department
A
I Congress Street, Stjjje.j()0
Poston,JVA 02114-20.17
www-maYs.gov1di(j
Workers' Compensation Insurance Affidavit: B uilders/cont,,,ctors/El ec tricia ns/Pi ii it, rs.
NUTTING AUTHORITY.
Aimlicant Information TO BE FILED WITH Tljj�PERi be
Nalne (Bl'silless/OrgaiiizatioiiAndividLial): Please l"ri t Legibly
Address:
City/State/Zlp:
C3
Areyp an employer?checktbc,.,p, _3
Lv_j am a employer with appropriate box:
_CITIPIoYccS(full and/or part-time). '1'yPe Of project(required):
7. F-1 New construction
2. am sole proprietor or partnership and have no employees working fi)l-role in
any capacity.(No workers'comp. insurance, required.] 8. 0 R.elnodelinp
3. 1 am a h0mco,,vner doing all work myself[No workers'comp.insurance required.]tq. F1 Demolition
4.r]I am a homeowner and will be hiring contractors to conduct all%vork on I,,),property. I will 10 ❑Building addition
criswe that all contractors either have workers'compensation insurance()I arcsole
Proprietors with no employees.
Electrical repairs Or additions
5.r 12. repairs additions
Plumbing 1 -is 01
I wn a general contractor and I have hired the sub-contactors listed oil the attachc(I.31ject.
'fhesc sub-contractors have employees and have workers'comp.inSUrariccJ 13. Roof repairs
G.Cl We are a corporation and its officers have exercised their right of'exciription per NIGL c. Otlie,
152,§1(4),and we have no,employees..nplo'Yees.[No workers'comp.insurance required.] 14.r
that checks box
W.W.-P p I�C-I t f�1711 Out'the section below hmvin9 ____—
their workers'compensation P0hGY information.
`Contractors that ch all work and flicn hire outs contractors must submit a IJC�V affidavit jud;C
Homeowners who submit this affidavit indicating they are doing
check this box must attached all additional sheet showing the name outside c 5
employees. If the sub-contractors have em loyces, I indicatin I- C.1
0 O'LthC sub-contrPcIol s and state Nvhetllcl-of not those ".t:
P _ they must provide their workers' entities ila'.'c
s comp.policy
am an employer that isprovidingworkers'compensation nsilensalion i
information. 1-allce-f0l.111Y en7P1(jj1eeS- Below is thepoli(y andjohsilt
Insurance Company Name: A/t;_
pOli(',y 'or Scif-ills.Lic. 4:. fVe C_-
Expiration Date:
Tob Site Address: Ile'�t
L-4- --f\t
4L
Attach a copy Of_the__ Workers' coinpN
ena�io�jpolicy declaration pa-e(showing
,the policy number and expiration date).
Failure to secure coverage as required under MGL C. 152, §25A is a criminal violation punishable by I tine UP to S1,500.00
and/or one-year imprisonment,as well as civil penalties ill the fol
day al, -in Of,,STOP WORK ORDER.and a rine of tip to 5250.00 a
_,ainst tile violator.A copy of this statement ma be forwarded to the of 1re of ,IN est,
verification, „atiOns OCtlic DIA for insurance
coverage verif y Office
do—hereby certify n cier t I ns and penalties of perjury that the lz�(10M'a It)"pfl'e;vi;ezd7�above is true and correct.
ir
1�1�Ln�a_tue I Mw, Pik 1
-J!,
fill_01i�i_
Official use 0111j). Do not 1pl-ile,in this area, to be completed by city Or tolvil official.
City Or TOW11:
certify n4er 11,
--------- Perinit/License#
'e.town
e I
0 (,i(
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3. City/'Town I FOW11 Clerk 4. Electric
6.Other -al juspe.(�toj_ 5. Pltlrnl)in.('Inspector
Electrical
-1 llpo�". I o`
Contact Person:____ Phone H:
07/01/2015 09;21 Nei I & Neil Insurance Agency (FAX)14137316629 P.001/001
A'ca� CERTIFICATE OF LIABILITY INSURANCE °A07/01/20'115'
THIS CERTIFICATE 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 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 policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions pf the policy,certain policies may require an endorsement, A statement on this certificate dogs not confer rights to the
certificate holder In Ileu of such endoreement e.
PRODUCER rN M,. David Jerry.
Neill&Neill Insurance Agency Inc PHONE
882 Riverdale Street (a13)7321137 (413)731-8629
West Springfield,MA 01089 AODRe
rN R AFFORDING COVIRAG,4 MAIC M
INSURER • State Auto Insurance Company STA
INSURED Michael Farelll Electrical E Acadia Insurance Co; 31325 .
8 Applewood Lane
Methuen,MA 01844
au ER o
N .
INSURER F t
COVERAGES 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 TYPE OF INlURANCE WAR VAM POLICY NUMBER IMMIXI ANSWI LIMITS
A GENERAL LIABILITY SOP2745517 08110/2016 08/10/2018 EACH OCCURRENCE ! 1,000,000
DAMACOMMERCIAL GENERAL LIABILITYE TQ ! .60.000
CLAIM$•MAOE OCCUR MED EXP(Any oneperson) $ 51000
PER SONAL&ADVINJURY $ 11000.000
09NERALA(iGREI3ATE ! 2.000.000
OEWLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/01 ! , 2.000.000
POLICYFI LOC _
AUTOMOEILa LIARiUTY
ANY AUTO BODILY INJURY(Par person) a
AUTOS ED AUTOBULfiO BODILY INJURY(Per evident) it
NON-"90 !
HIRED AUTOS AUTO$
a ♦ _
UMBRELLA LIAR OCCUR EACH OCCURRENCE b
i
111tCESS LIAR
HCLAIMS-MADE AOGRIiGATS !
DED RKTEWnON! a
CAKERBCOMPENSATION WC-20-20.001461-0503:20/2015 03/2012018 A u• H.
AND EMPLOYERS'LIABILITY YIN
ANY PAOPRILrTORIPARTNSR/sXtCUTIV$ N/A 91.FACH ACCIDENT y 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E,L.DISEASE•EA EMPLOYEE ! 100,000
If as dascdbo under
RIPTIO QF QPC RATIONS WOW E,L.DI$EASE•POLICY I'MIT a 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD I Of,Additional Remarks Schedule,If more apaca Fa required)
Faxed to: 978-682-1480
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TH6 ABOVE 068CRt1160 POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1600 Osgood Street,Building 20 ACCORDANCE WI E POLICY PROVISIONS.
Suite 2035 a
North Andover,MA 01845 AUTHORIZED REPRFs TA r, r N
rM. r
s
1988•x010 ACORO C PORATIO rights reserved.
ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD
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