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HomeMy WebLinkAboutMiscellaneous - 158 Kingston Street 1 S 7F r` � - L Date.........!.. .. .......................... OF NOR7#I i oma; oom TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ♦ ;?7"�T-:`:fig `4SACHU5� i 1 I Thiscertifies that .............'.C............ .....................e......`..................................................... i has permission to perform .....! .4tt�1I 1....(:r', c.�o @ .�. wiring in the building of.......... ' at ............�:. �� .......1.......-�Jam. ? .... �North Andover,Mass. Fee.... . ...l......Lic.No.--.ICa ........................:. ELECTRICAL INSPECTOR Check# Commonwealth o���ass a��e(f� Official Us/e,Only - Permit No. �JePartmeiz�o�J`iFe�erviced BOARD OF FIRE PREVENTION REGULATION Occupancy and Fee Checked (leap e blah};)" up PPUATION FOR PERNMT TO PERFORM ELECT CAL VV❑R All work to be performed in accordance with the Massachusetts Electrical Code E� (PL'ASE PRINT'A"_1K OR TYPE XLL INFOR TIOl!) Date. cMEC) 5z7 CMR I z..00 MY or Town of: _A&Aln AA• By this application the undersigneti gjves notice of his or h�� ntion to perfo To t,Zthe jel�ctrical described below. Locadan (Street&Number) h 6 1/,,, S, Owner or Tenant l' Owner's address ��, "Telephone No. I VA r Is this permit in conju tlon with a build€ng permit? yes No Purpose of Buil 4 r (Check Appropriate t✓ox � P dm P 1 Building ,61 � Udlity Authorization No. Existing Service� , (� Amps / q6 Volts Overhead ❑ Undgrd � No. of Meters 1 New Service l� Amps / q Volts Overhead❑ Undgrd No, of Meters ! Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: cc Completion of folio in table may be waived by the Ins echof Wires. Nc. °�Recess�edLum inaires �No.of Ceil.-Susp.�raddie)Fans N0°°f Total No. of Luminaire Outlets Transformers KV A No. of Hot Tubs Generators KVA No, of Luminaires Swimming Pool rnd e In- ❑ o. o mergency lg ting ., rnd. Baftery Units No, of Receptacle Outlets No,of Oil Burners iFIRE ALARMS No. of Zones No. of"Switches No. of Gas Burners No.of Detection and No. of Ranges Initiating Devices No.. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons.. .KW INo, of S:t: Contained Totals: """" "" ................... No. of Dishwashers Detection/Alerting Devices Space/Area Heating IC�Tr' Local❑ Municipal Connection ❑ Other 31 No, of Dryers Heating Appliances KW Security Systems:* No, of Water N KW o. No.of Devices or E uivalent Heaters of No. of Data P4 irin Signs Ballasts e �\ No. Hydromassage Bathtubs No.of Devices or Equivalent �\ g No, of Motors Total HP Telecommunications V1,iring; OTHER: No.of Devices or E uivalent Attach additional detail if desired, oras required by thInspector of R Cres' Estimated Value of ectrical Work: G (When required by municipal policy.) Work to Start: 9 Inspections to be requested in accordant n. INSURANCE e with MEC Rule 10,and upon co CO RAGE: Unless waived by the owner,no permit for the performance of electrical work mayissueunless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of same to the permit issuing offi CHECK ONE: INSURANCE BOND [] OTHER ❑ (Specify:) CC. !certify, under the pains and penal[" s of er'ury, that the information,on this application is true and co FIRM NAME: complete, LI Li �`' c.NO..-,A Licensee: •Cuff)II Signature (If applicable, ent exempt' in he license number line.) r e LTC.NO, Cj Address: i[7wC-MC L A e� ® Bus. Tel.1�!0.; *Per M.G.L c 147, s. 57-6 1, security work requires Depar hunt of Public Safety"S"License:6 qy Alt. Tel. c.No, t` OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement, I am the the Owner/. Q ch Owner/Agent ( one)❑ owner ❑owner's a ent. St nature b Telephone No• PERMIT FEE. $ I Ute/UJI LU 10 UO;JO IVC i I a IVC I I I nsu ranee Agency 9 ) (r•Ax)14137316629 P.001l001 a i I�tCR.L.it� F1 CERTIFICATE OF LIABILITY INS�JRANG' TE(MMIDDM'YY) E DA09/03/2015 THIS CCRTIFICATtE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THI; CQRTIFICATE HOLDER, THIS CERTIFICATE DOLS NOT AFFIRMATIVELY OR NEGATIVELY AMEND,,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT C0NSTIYUT6 A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLD9R1 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 of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the Certificate holder In HOU of such endorsement(s), PRODUCER QQNTAGT Dav d Jairry Neill&Neill Insurance Agency Inc NAMM' 662 Riverdale Street11 , (413)732.4137 "oc Ne:(413)731-6629 We6t Springfield,MA 01089 B•M IL ADORE Bt INSUR9151(fill AFFORDINOCOV6RAGG NAIC0 INSURER AI State Auto:insurance Company STA INSURED Michael Farefll Electrical IN3URHR a: Acadia Insurance Co, 31325 9 A lewood Lana Methuen,MA 01644 INSURFR0: NSU E D• . L INS RFA F, IN9URfiR J:: i I 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 PAtb CLAIMS, INSR IPINURADMPOLICYNUMikR M D LIMITS A GENERAL LIABILITY BOP2745517 06/10/2015 06/10/2016 r r EACgOGGUARBNtC i 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TD R PREMISES(Gorr n 3 40,000 I CLAIMS•MADB t v 1 OCCUR MED EXP(Any one arson 6 5,000 ---- -- PBRSONALAADV INJURY 3 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS•COMPIOP AGO S 2,000,000 POLICY M- LOC I S AUTOMOaILE UA131UTY ANY AUTO 60DILY INJURY(Par parson) S ALL OWN90 AUTQSULfiO BODILY INJURY(Per a00d9no 6 NON-OWNED PRO ERTY AMAGE i HIRtOaUToB AUTOS p n . s UMBRELLA UAB OCCUR EACH OCCURRENCE i EXCeSS UAa CLAIMS-MADE AG00111ATfi 13 DED-7 RETCNTIQN 6 ( If B WORXgR$COMPENBATION; WC-20.20.001461-05 03/20/201$ 03/20/2018 0TRH• AND BMPLGYBRa'UABILITY ANY PROPRIETORMARTNERISXECUTIVE YIN OFFICERIMEMBER EXCLUDED? M NIA 6L,EACH ACCIDENT 6 100,000 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE 3 100,000 Me dewh0under RIPTION OF OPERATIONS below E.L,DISEASE POLICY LIMIT S 500,000 i DBSCRIPTICN OP CPLRAMONS I LOCATIONS i VBHICLES(Attach ACORD 401,Additlenal Romarko Schedule,Ir mon apace to mqulrvdi Faxed to: 978-682.1480 E� I r I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DE$ORIBED POLICIES BE CANCELLED BEFORE Town of North Andover TH EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVERED IN 1600 Osgood Street,Building 20 AC:ORDANCE TH THE POLICY PROVISIONS. Sults 2035 i North Andover MA 01845 AumoRitaD RI:P 8Ei Ami ('01888-2010 ACORDWORPORAIXWAII rights reserved. ACORD 26(2010/06) The ACORD name and logo are regia eyed marks of ACORD The Commonwealth of Massachusetts u Department ofbidustt'ialAceidents r 1 Congress Street, Suite.X00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation nsation Ins P urance Affidavit:B u llde rs/Contra ctors/Electricians/Plumbers. TO BE FILED WITH TTS 1'EI2MITTING AUTHORITY.Applicant Information Please Print Legibly Name (Business/Organization/Individual): � ,�t.�i City/State/Zip: in APYIPhone Are yqp an employer?Check the appropriate box: ©f 1. I am a employer with__employees(full and/or part-time). Type of project(required): 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, R-emodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself t. 9. ❑Demolition ❑ g y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 L VF,lectrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-ccatractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance. 13•[]Roof repairs 6.❑We area corporation and its officers have exercised their right of exemption per MGI,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. i Homeowners who subunit Ws 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 the policy and job site information. Insurance Company Name:_&- , i d =-LAU Y,7Cc - jtd` Policy#or Self-ins.Lie.#:_ }C. - tV -r) a ()C" La` -' __- Expiration Date: Job Site Address:A !_!C=A, -AA ,% City/State/Zip: c(A ,4U f A4, Attach a copy of the workers' cornpensation 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 Izereby eertify.0 der the ins anndjpenalties gnfperjuiy that the informationprovided above is truce and correct. Sig-nature: —1 I 0 ' ? 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#: