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HomeMy WebLinkAboutMiscellaneous - 19 ROYAL CREST DRIVE 4/30/2018 � y RyA � cum 1 BUILDING FILE � Date....................... .................... OF AORrh,� TOWN.: OF NORTH ANDOVER PERMIT FOR WIRING obt SS�CHUS� j Thiscertifies that .......................................................................................... . . ................................. has permission to perform�� ................................ .... ....�...t..c.'..... j;ff ring in the building of. .. ....`MCO Q . ..............1.............. ................................................ ............:......� .. Utas •.L� .............. North Andover,Mass. ti� Fee.... . 1.........Lic. No. . .! {{ .............................. ELECTRICAL INSPECTOR Check# � 1 2 Commonwealth of Massachusetts Official jUse Only Permit No. Department of Fire Services Occupancy and Fee Checked a� BOARD OF FIRE PREVENTION.REGULATIONS [Rev.l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN HK 0R TYPE ALL)NFORMATION) Date: P Ue4 u 5 t ;(6 . I Lt City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) '50 Q O U CIS ( Cr4 s+ )-.- Owner or Tenant AM`C Q 146 rZ.•`I-h A N Dtiv-ev- �'.. Telephone No. Owner's Address bu i Ipti rNf 9 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CI eCs G'�eC ►2 tC ( [' 5nn�C-I-�css1`S i M �52�' �� eledrLi c, 1-ko-+ I V n e va I �-se. 4-h{r nR e s taJ-S (1n e �C� -� b �c�k 5 F�ePJ i►'�ct t-h-w-S e 'u n i-�—' Completion of thefollowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA a No.of Luminaire Outlets No.of Hot Tubs Generators KVA _ No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: """"' " ' ..........."' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: ' No.of Devices or Equivalent 11 OTHER: ®� Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: s (When required by municipal policy.) Work to Start:8(ol le I i Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify,under the painswand alt' !f jury,that flee information on this application is true and complete. FIRM NAME: ®� 1 e. P� Y l tile- LIC.NO.: A 15'79 q Licensee:bw e—I P, yl I-a-1 e— Signature P LIC.NO.: 3 16 150 g (If applicable enter�exempI Cin the license number line.) m r Bus.Tel.No.: Address: '1 fr t Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. � 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(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: s� 2-c7— Signature Telephone No. The Commonwealth of liMassachusetts Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): l 1Py 1 Q , e—(07"L )•(r, Address: City/State/Zip: a, A_U_L1 C'-Wl �f l (fat 1 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 4. ❑ I am a general contractor and I ` 1.❑ I am a employer with 1+ g 6. ❑New construction employees fu11 and/or part-time).* have hired the sub-contractors � p ) 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other 'Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. T"Homeowners who submit this affidavit indicating they a"re 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. AL ��c� ry i C i Policy#or Sol£ins.Lic.#: W C-C. 5C()(0'6� � }�{ Expiration Date: ` f Job Site Address: Jr ���ec-1 c r"�� 'D 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 of MGL o. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do h ergbqtpertunder the pains antdpenaldes ofperjury that the information provided above is true and correct. Sim ature• `y Date: e (q(a 1 �' 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#: —, COMMONWEALTH-OF MASSACHUSETTS ELWTI ANS ISSUES THE -FOLLOWING LICENSE AS :A < REGl:STfRED MASTER :ELE�TRICIAN> fee: \ $ DANIEL P VITALE 190 DALE ;,ST', Z WALTHAM J MA oz451-3773 ` 15795 ;A 07/31/16 35001 -� 4 B 1 4 COMMONWEALTH.OF.MASSACHUSETTS :j ! ' ® • • ® • BOAKD+Cf €I�ECT�t I C.ANS ISSUES THE FOLLOWING LICENSE I' `a AS A. R1 G JOURNEYMAN .ELECTRICIAN DAN.<IEL P VITALE \ 190 DA E. z i WALTHAMMA 02451-3773 J 3 i 850'>€ 07/3.111 b 35002 14.Guo o, rcx30 l ® DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 8/26/14 116IS 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(ies) 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 lieu of such endorsement(s). PRODUCER CONTACT NAME: LESLIE HANNON James O'Connell Insurance Agen PHONE FAX (978) 667-6150 A/ No: (978) 667-0587 572 Boston Rd ADDRESS: JIMINS@OCONNELLINS.COM Unit 7 INSURERS)AFFORDING COVERAGE NAIC# Billerica, MA 01821 INSURER A:Merchants INSURED INSURER B:A.I.M. Insurance DANIEL P VITALE ELECTRIC INSURER C: 190 DALE ST INSURER D: WALTHAM, MA 02451 INSURER E: INSURER F: 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. INSR ADDL SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAM"GETORENTED-PREM SE occurrence) $ 500,000 CLAIMS-MADE a OCCUR MED EXP(Anyone person) $ 15,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS _ AUTOS Peraccident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC5006538012009 10/11/13 10/11/14 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICE RIMEMBER EXCLUDED? N/A — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yyes describe under DESIRIPTIONOFOPERATIONS below E.L.DISEASE-POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is regui red) ELECTRICAL WORK CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE , LESLIE HANNON ©1988-2010 A ORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: