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HomeMy WebLinkAboutMiscellaneous - 2303 TURNPIKE STREET 4/30/2018� �� � 11)µ 1 Date........................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....V.v"Y ..................'.......................................................................... has ermission to erform p _ ` @1►._ �+ �� . P..................................................................................... wiring in the building of........�2r............................................................................... at ..................................... RN (�.....�-t , Nrth Andover, Mass. .......................... Fee.. ................ Lic. No.�.........b..... Yl <'- ............� ` F.1 PCTRICAI. TNSPF(-TC)R Check # +� M6� Commonwealth of Massachusetts OfficialUseOnly Permit No. Department of Fire Services Occupancy and Fee Checked 'j BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I City or Town of: No ,-t A To the Inspector ?fWires.* By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Z363 T0,-hAAP— 7L Owner or Tenant MAel Owner's Address Z.� 0 A TJ,-�, D i K?- 5 �- Is this permit in conjunction with a building permit? Yes Purpose of Building D ✓Q 1 ,'r � Existing Service Amps / Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: T tinb �e_ r �t A � }-�t,11 � � ��f, � �1 �j,i s , �.i 11 5 +-, Tn( A (I Npi. .,/ /ti17.kD r), 14-1, 4 - Completion of the following table may be waived by the Inspector of wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA !No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In rnd. Elrnd. ❑ o. o mergency Lighting Battery Units jNo. 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 Tons No..of Alerting Devices g No. of Waste Disposers Heat Pum Totals I.Number I.Tons KW No. of Self -Contained 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 Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent rA BOTHER: AttaCh additio;201 detail if desired, or as required by the Inspector of fires. Estimated Value of Electrical Work: 4300. (When required by municipal policy.) Work to Start: b ZZ I I Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERA61: 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:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Joseph C Mahoney - Licensed Electrician LIC. NO.: 1718JR Licensee: Joseph C Mahoney Signature LIC. NO.: 1718JR (/fapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: (603) 347-8969 Address: 3 Toppan Rd Kingston, NH 03848 Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner E]owner's agent. Owner/Agent Signature Telephone No. b� PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of'Investigations 600 Washington Street Boston, MA 02111 www.mass.,ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Joseph C Mahoney Address: 3 Toppan Rd City/State/Zip: Kingston, NH 03848 Phone #: (603) 347-8969 Are you an employer? Check the appropriate box: Type of project (required): ,\ 1. ❑ l am a employer with 4. [:]I am a general contractor and I ❑ ruction employees (full and/or part-time).* have hired the sub -contractors 6. New const 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition eb working for me in an capacity. employees and have workers' o Y p h'• _ 9. F-1 Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation and its 10.® Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] c. 152, § 1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks bos #I must also till out the section below showing their v.orkcrs' compensation policy information. Homeowners who submit this al3idavit indicating* they are doing all work and then hire outside contractors must submit a new allidavit indicating such. 'Contractors that check this box must attached an additional sheet showin` the name of•the sub -contractors and state whether or not those entities have employees. Ifthe sub -contractors have employees. Ihey must provide their +orkers' comp. policy number. / am an employer that is providing workers' compensation insurance./or my enrplt )yeec. Below is the policy and job site infirmation. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: All Jobs in the City/Town of No,'i'h City/State/Zip:MA— , _t) � Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL. c. 152 can lead to the imposition of criminal penalties of fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a tine 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. .1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. (603) 347-8969 Official use only. Do not write in this area, to be completed by cit)' 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 #: I" LU Co.) Co La L-3 CD —j co w. s", ROK �- CERTIFICATE OF LIABILITY INSURANCE R045 DA"Iti IMM/DD/1'YYY) 6/18/2015 THIS CERTIFICATEIS 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 SUBROGATIONIS 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 NORTHEAST AGENCIES INC/PHS 210619 P:(866) 467-8730 F: (888) 443-6112 301 WOODS PARK DRIVE CLINTON NY 13323 CONTACT NAME' (acN.Ext): (866) 467-8730 (Ac.Ne): (888) 443-6112 AD`DReSS INSURER(S) AFFORDING COVERAGE NAIL# INSURER A: Hartford Casualty Ins Co INSURED JOSEPH MAHONEY 3 TOPPAN RD KINGSTON NH 03848 INSURER B: INSURER C: INSURER D. INSURER E: INSURER 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. /A'SR TTR\- TYPE OF IA'SUR.4:NCE ADDL SURR { ' POLICY:NUMRER POLICYEFF lMM/DD/YYYY POLICYE.VP d LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s500,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) s300,000 MED EXP (Any one person) $10, 000 A X General Liab 01 SBM AR4437 09/11/2014 09/11/2015 PERSONAL 8 ADV INJURY 5 0 0, 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE c1, 000, 000 POLICY X PRO ❑ LOC )ECT PRODUCTS - COMP/OP AGO $1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) ; PROPERTY DAMAGE (Per accident) HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE EXCESS LIAB CLAIMS -MADE DED I RETENTION 5 "'OREEH.S COI/PE,NSI TION PER OTH- .IND EIIPLOt'ERS'LL4R/LITY STATUTE ER E.L. EACH ACCIDENT ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED?NIA (Mandatory in NH) ❑ - E.L. DISEASE- EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below $ E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A UTHORIZED REPRESENTATIVE Town of North Andover 1600 OSGOOD ST STE 2020 NORTH ANDOVER, MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD NORTHEAST AGENCIES INC/PHS 301 WOODS PARK DRIVE CLINTON NY 13323 Town of North Andover 1600 OSGOOD ST STE 2020 NORTH ANDOVER MA 01845 ACORD 25 (2014/01) e