Loading...
HomeMy WebLinkAboutMiscellaneous - 24 ROYAL CREST DRIVE 4/30/201817- t Date ���... �.�.�'...k TOWN OF NORTH ANDOVER PERMIT FOR WIRING L �� �(e AW.Mt-AA�A0,J This certifies thae has permission to perform ... . jC2...... i.......1..11..P.v. nn.6 `> ; Xj AA')t.0 wiring in the building of...._..1........................................................................... C'�.....�712—,Nh hAndover, Mass. Fee.... c .r') `..`....... Lic. No. L.a �............'c!...................... � .................:.. f 1... ELECTRICAL INSPECTOR / Check # (/ 12I7� y a- Commonwe'aith of Massachusetts official use only Department of Fire Services Permit No, ��� (r T BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (PLEAAli work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 SE PRINT IN INK OR TYPE AL4 INFO City or Town of: NOY �, TION) Date: � By this application the undersigned gives notice o Ns o© r er t�nt\ niton to perform hTo e of fres: Location (Street &Number) , e electrical work described below, R2�l Cr-�,S`5' 1�rl htr� Owner or Tenant A� ea NOS E 1kN•:�r�Y^ M� O I W4 5 t Owner's Address �'� LU e' Telephone No, 97� 6g� 7dOC� �® l C`ie� Is this permit in conjunction with a buildingNdF+V Q t Fs �� r Purpose of Building permit' Yes ❑ No '-�.... t ~ -- �weL; (Check Appropriate Box) Existing Service Utility Authorization No, Amps / Volts Overhead ❑ U -------- _ ud rd Amps / g ❑ No. of Meters Number of Feeders and Ampacity— —Volts Overhead ❑ Und rd 8 ❑ No. of Meters Location and Naatuuree Of Proposed Electrical Work: . nc _''--I -!_ �.e N JJg. 1 l� lA / --', �tai _.... V, r�a�tta a5— - Nu it No. of Recessed Fixtures tetion o 'the oliowtn table ma be waived by the Ins ector o Wires. No. of Lighting Outlets To. of Ceil.-Susp. (Paddle) Fans o. o ransformers No. of Hot TuKVA Tubs Generators KVA�— No, of Lighting Fixtures Swimming Pool rn ve ❑ n- ❑ °' ° rner; , g ng No. of Receptacle Outlets Baas Units i — No o: O;1 Burners No. of Switches FIRE ALARMS [No. of Zones No. of Ranges No. of Gas Burners o, o otec ori tl No, of Air Cond, otal Initian Devices No. of Waste Disposers Tons No. of Alerting Devices ea ump um er ons No, of Dishwashers Totals: o o e - onta ne Space/Area Heating KW Detection/Alertin Devices No, of Dryers Local ❑ un c pa Heating Appliances annection C3 Other 0.0 ater KW ecur ty stems: Heaters KW .010 010 No. of Devices or Eg ulvalent Sims Ballasts Data Wiringg YiM¢aT ONo. Hydromassage Bathtubs NNo. f Devices or E uivalent No. of Motors Total HP a ecommun cat ons r THERng; : �j mzc� �; C Se � � J'No. of Devices or E uivaient in ty i S 3 Wall t n N 'tier N.ta INSURANCE Sra�- COVERAGE; Unless waived by the owner, no permit for the performance of electrical work may i Attach additlono! delart 1J'deslred, or os regtnred by the Inspector of Wirer, the licensee provides proof of liability insurance including `bompleted operation" coverage or its substantial equivalent. undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. y ssue unless CHECK ONE: INSURANCE q nt. The BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work yNZO' Z (When required by municipal policy,) IExtra phon Date) Work to Start; Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties o FIRM NAME: t`)P,=,J,) `,�. fp er ju ry, that the Information on this application is true and complete, Licensee: IC • NO.: Q O ci. (Ifapplicahte enter "� Signator L �' Address: Ci empt to the licepse number line,) LIC, NO.: (p O OWNER IS CNSU � � Por' c�� Bus. Tel. No. - RAN E WAIVER: I O A� `( a , 77 required by law. B 8 am awy e that the Licensee does not have the liability Alt' Tel. No.- - 3 Owner/Agent y my Signature below, I hereb waive this re uirement. I am the check one q ( ty insurance coverage normally Signature owner owner's a ent. Telephone No. PERMXT FEE: $C) I n'o (.OM010nwealth of Massachaseats ,Department of.Industrial Accidents Office ofJ.nvestigations 1 Congress street, Suite 100 Boston, MA 02114-2017 WHIM)'MaSs govIdia Workers' Compensation Insurance ,Affidavit: Builders/Contira.ctors/Electriclialls/Plumbeirs Annliicnnt Name (Busit)ess/Organization/Individual): Address: City/State/lin: C_ Phone i$: Aou an employer? Cheep the appropriate box- IjN I. am a employer with 4. I am a. general contractor and I employees (frill and/or part-time).* have hired the sub -contractors 2. ❑ I am a'sole proprietor or partner, listed on the attached sheet, slip and have no employees These sub -contractors have working, for me in any capacity, employees and have workers' [No workers' comp, insurance comp. insurance, k required.] 5. EJ We are a corporation and its 3. ❑ I am a homeowner doing all worlt, officers have exercised their myself. [No workers' comp. right of exemption per MOL insurance required.] t c. 152, §1(4), and we have no employees. (No workers' Co _31 050? Type of project (required): 6, New construction 7. Remodeling S. Demolition y• ❑ uilding addition 10101 103eElectrical repairs or additions I I.❑ Plumbing repairs or additions 12.[f Roof repairs 13.❑ Other *Any applicant that chocks box it comp. insurance required.] must also till out the section below showing their workers' compensation policy information. 'I' Homeowners who submit this affidavit indicating they are doing all work and then hire outside cpntractors must submit a new affidavit indicating such, naplo ucs, that cheek this box must attached an additional sheet showing the name of the sub•crantractars and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp, policy number, 1 am an employer that is,providing workers, compensation insurance for my en rmation> ploy¢es. Below is floe policy urrd job site t<r. l fo Insurance Company Name: 4 Policy # or Self -ins. Lic. #, L R U. Expiration Date: Job Site City/State/lip: 1If i 4/ S -Y f 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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the ,DIA ,for insurance coverage verification, I do /rereb cerci I; under tfi am Lpndpena)ties o ger ur, that the in ornration provided above is true and correct. -I— Official if A Official use only. Do not mrite in this area, to be corn pleted by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building )Department 3. City/Town Clerk 4, Electrical Insvector S. ptnmh:"a Tmb...,.t__ 6, Other Contact Person. - Phone #• '4 QR0� NE�/P013 OP ID: LS �►--- CERTIFICATE OF LIABILITY INSURANCE[!DATG(MMrOOYYYY) :REPRESENTATIVE ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIQHT3 UPON THE CERTIFICATE OLDER' FICATE b0E3 N07 AFFIRMATIVELY OR NEGATIVELY AMEND, HIS W. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE AT CONTTRACTTBETWEENOTHE ISSUINVERAGE G NSURER($)TAUTHORIZED OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(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 Ileu of such endorsement s PRODUCER DF Dwyer AgencyD.F. D e Agency er Insurance 38 Bellevue Avenue NAM P e—/ -- Newport, RI 02840 Daniel F. Dwyer III 401-848-9829 , srWV2.em. eIMf� A#A... __ __W /a ,01-846`9829 __,NA INSURED p--.._..-._..-....-......................—� INSURER A: Foremost Newport Electric Construction ----�._____ _ __ _ __ _ Corp INsuRE_ Re:Scattsdale Insurance Company 41297 200 Hlgh Point Ave, Suite B6 INSURERC: Beacon Mutual Insurance Portsmouth, RI 02871 -------- THIS _- REVISION N MBER: I 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, TYPE OF INSURAH1Ce ABB _._.---._._.__.-_-.__._- _� GENERAL LIABILITY POLICY NUM R LIMITS A X COMMERCIAL GENERAL LIABILITY SCP00604644$ EACH OCCURRENCE E _ 1,000,0 12/30/2013 12/30/2014 CLAIMS MADE D OCCUR 9ccurrenoel E 300-Oi DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attooh ACORD 101, AddMonal Remarks Schedule, N more spaos is required) F THE THE SHOULD EXPIRA OOt DATE VTHER OF�ENOTICE POLICIES EE CANCELLEDWILL LIVEREO RN Insured's Copy ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel F, Dwyer III ACORD 26 (2010/06) The ACORD name and logo are registered m988-20 CORD D CORPORATION. All rights reserved. PERSONAL 8 ADV INJURY 1 E 1 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 POLICY 71 PRO F7,OC _ PRODUCTS -CO P/OPAGG S 2 AUYOMOBILE LIABILITY E A ANY AUTO OMBI D SIN L L I AUTOS ALL OWNED X SCHEDULED SCP005046448 12130/2013 12/30/2014 I anti 1 BODILY INJURY IF person) E -� AUTOS HIRED AUTOS X NON -OWNED AUTOS BODILY INJURY (Per accident) $ PR PER TY D E — -- E UMBIIELIA LUIS X OCCUR E B X EXCESS LIAN CLAJM84AADE 880019698EACH OCCURRENCE D TE I N 12/3012013 12/30/2014 AGGREGATE E 6 WORKERS COMPENSATION "'^--- AND EMPLOYERS' LIABILITY E C OFFICER/MEMBER EXCLUDED? ECUTIVE Ya N / A 68861 01/18/2014 WC STATU- 0TH• $ _ER._ - (Mandatory in NH) 01/18/2016 E.L. EACH ACCIDENT g ` `- If ee descr@e under D R PTI N F OPERATIONS below E.L. DISEASE - EA EMPLOYEE E� I A Elnpl Frac Llab SCP00504644$E.L. DISEASE - POLtCY LIMIT S 12/30/2013 1 12/30/2014 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attooh ACORD 101, AddMonal Remarks Schedule, N more spaos is required) F THE THE SHOULD EXPIRA OOt DATE VTHER OF�ENOTICE POLICIES EE CANCELLEDWILL LIVEREO RN Insured's Copy ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel F, Dwyer III ACORD 26 (2010/06) The ACORD name and logo are registered m988-20 CORD D CORPORATION. All rights reserved.