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Home My WebLink AboutMiscellaneous - 148 MAIN STREET 4/30/2018 (4) �. � - �a-- • I{ Date...... ..... .. :..f. ... NORrh f °� "" '•�� TOWN OF NORTH ANDOVER n PERMIT FOR WIRING w:' ss�cHUss / � � le�.../...�. ............ .L........ This certifies that ............( . T '' ...1.�!............�r..... has permission to perform .......�� G < <f.......C..��..1................................ wiring in the building of........ ..................................' '� ...............1..........:s..r.................... at ........../ . .............k.North Andover,Mass. Fee.....f �-......Lic.No.I GG 1 1�.:. ....'c-rwu 1 v- ........................ ................................... ELECTRICALINSPECTOR Check# � rI :JJJ� s► r� a //l atlut�a i officio useOnly 0 �aparrenfa�.�iee� Permit No. BOARD OF FIRE PREVENTION REGULATIONS Oaarpanr.Y and Fee Chedmd ' Omft bhmti APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Alt wrorlc b be performed is accordance wigr tbeMass�hase�fiat Code(Td�s27 CLaIIt 12� (PLUZPM fMAWORTPPEAL_ MORI"TION} Date: Clty or Town of: o )41l ✓J 0 Uc_fe To the hap ctor of By this application the undersigned gnus notice of his or her intention to pesfoan the electrical work deseabed below. Locatiop(Street tit Number) �/ /L-/12/,0 S % 0 14 / S _1? v?To N 1�cis r Owner or Tenant D o C �l ,y /� hi L t/ - �-- Telephone Na Owner's Address • Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate P�ox) *' Parpose'of Building Q Lt✓a i/ !n c. UtHity Authorization No. E sting Service P/1 Amps 1 Volts Overhead❑ IIndgrd❑ Na of Meters New Service Amps Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Worms T 10 /S n s Q I S /a nCwwktfon table be waived by du Wirer Na of Rued Lem hmh-es Na of CeL4usp.(paddle)Fans 140.Of Transformers HVA Na aflAndRAIM Oatieft No,of Hot Tabs Generators KVA Na OfLlnnhHdires Swlmmingpool Alk ❑ ❑ Ba o eryIIIIicy XMIts No,ofRseeptade Outlets Na of 013 Burners FIRS ALARMS Na of zoaea No.ofSwitches No.of Gas Burners 140.011metection an Devices Tons No.of Ranges Na of Air Cond. Tons o-ofAlerting Devices No.of Waste Disposers ToP ons o.oSen-Contained et Wdon/Alerfing Devices Na of Dishwashers Space/Area Heating IOW Connection ❑ Other No.of Dryers Heating APpliances KW f evices°r ent -r a water KW a o a of SS allasts Data Whi°� i BNa ofDevices or tQUIvalent ' NoHydromassage Bathtubs No.of Motors Totai HP TaeconimunicatiNa of Devices oar Yfirin ent OTHER: Estimated Value ofEkx trical Work: Ancchad�dvnol detail ifde k,4 oras mqubzdby dohspeatarofWg,& (Whm•rophW by municipal policy-) Work to StmtInspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no penult for the performance of electrical work may issue unless the 11000M provides proof of liability insurance including ftompleted operation"coverage or its substantial undersigned certifies that such coverage is in force,and has exiuUW proof of same to the permit issuing offices The aMM ONE: DW ANCEt2 BOND ❑ OTHM ❑ ( :) I cefy,urrderAePab's andpen dd a ofpeUkuy,that the Informattanr on this ONHeadon is hueand conrplet. =mNAM&BUM7 Electric Inc. Vincent B. Landers JrgignLtC:No� 12017 A Licensee � (�-7 y� �� C.N�23 84 E Afeffuoabk.enter cwnpt"m the Itce=maaber rum) Bus_ eL No.. Address: _24 Colgate ni. N Anclnvar — — 455 *Par hLG.L.a 147,s.57-61,security work ,tea,IRA& Alt Tel.No.� OWNER'S INSURANCE W of Public Safety"S"License: Lia No. AMM I am aware that the Licensee does not have the liability insurance oove=Mge normally required by law By my signature below,I hereby waive this tequh=WL I am the(check one)❑OwnWAgeut owner ❑owner's a geaL Signatur,6 Telephone No. PERMIT FES s 3S�- The Commonwealth of Massachusetts - . Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibiy Name(Business/Organization/Individual):U ddvz ,( Address: L/ (� l d r r— City/State/Zip: ��' d 11 f" Phone#: 9_2er 3 25--Q 177 , Are you an employer?Check the appropriate box: Type of project(required): 1.$ 1 am a employer with 4. ❑ T am a general contractor and I 6, E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.®Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box41 must also fill out the section below showingtheir 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. ,050120,,(C-f_ rV2i AZe- Policy#or Self-ins.Lie.#: L'�" �(L ;� Expiration Date: Job Site Address:/4(9: Q l L1 s�• 14 Z City/State/Zip• Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or oneuyear 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert under the pains nd nalties of perjury that the information provided above is true and correct Signature: Date: 9 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#: WORKERS COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY—INFORMATION PAGE INSURER. POLICY NO: WCT2193D NGM INSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 - RENEWAL OF: WCT2193D JACKSONVILLE, FL 32245-6000 NCCI Company No: 16322 Account No: CACT2193D ITEM 1.NAMED INSURED AND MAILING ADDRESS: AGENCY NAME AND ADDRESS: BUDDY. ELECTRIC INC SEGREVE & HALL INS ASSOC INC 24 COLGATE DR NORTH ANDOVER MA 01845-1807 305 NORTH MAIN ST ANDOVER, MA 01810 AGENCY PHONE NO.: (978) 975-1300 AGENCY NO.: 201226 LEGAL-ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2. POUCYPERIOD: From: 01-22-2015 To: 01-22-2016 Effective 1201 A.M. Standard Time at the Insured's mailing address_ ITEM 3. COVERAGE: A_ Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. the limits of liability under Part Two are: Bodily Injury by Accident: $ 500,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 500,600 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: ND, OH, WA, WY and.states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 305 Annual Premium: $ 2,613 Audit Period: ANNUAL Date- 12-14-2014 Countersigned by WC 00 00 01 A Copyflglt 1%71 adoral Coudal on Conversation kmnanoe USUR®CON