HomeMy WebLinkAboutMiscellaneous - 290 JOHNSON STREET 4/30/2018N
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Date ..... :�� ... 7.71-161 .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... &A.9y ....
has permission to perform ..... 5rep
wiring in the building of .................... .................................
........... North Andover, Mass.
FeeYr c. NoJ:�AZ4 ........ Pa
CAL NSPE R/
Check # Z- 62—
C��
29111"Namm commemema 01 xja4dm" officialuseonly
ERNMINEM
PermitNo. el
28f a?&WdV/_7_W swdcoj - Z�0_ L/
BOARD OF FIRE PREVENTION REGULATIONS 0 ancy and Fee Checlmd
W b=m a. hl.m
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Ali w0*tobeperfi=ed kammdauwWi&%0j&Wach0sftEe*W Code (MQ, 327 CM1100
0)L.WBPMffBVM0AMEMZBff0M"7Y01V Date: '6
_/
CityorTownok AJO To the inypector �f Wires. -
By this application the undersigned gives notice of his or bar intention to perform the electrical wodc descrted below.
IA)MtIOJM (Street & Number) 0 n. Tj
Owner or Tenant 1-14
'7_41__�4 �641 Tidephone No,
OwneesAddress S
Is this permit in Conjunction with a building permit?
Purpose Of Building
Existing Service / (9 () Araps volts
NewService Amps -volts
Number offeeders and Ampacity
M-01
No R_ (Check Appropriate Box)
Utility Authorization No.
Overhead DUndgrd 0 No. ofMeters
Overhead n Undgrd D No. ofMetm
Location and Natam of Proposed Electrical Work:
r 7_�k A"-
No. of Recessed Luminaires
No. of CeEL-Snsp. (Pad4b) Fans
W"8WCUVYUW:4� Of WVW.
Nom Total
Transmormers XVA
No. OfIA011110811re Ontleft
No. ofHot-Tubs
Generators XCVA
No. of Immin
sm"U'UnIngPo-o" ;Zi,
0
r "gmg
_i�
fttte units
M
No. of Receptacle outlets
No. of On Durnen
-
FIRE ALARM
No, of Zones
No. of Switches
No. of Gas Burners
N—O- 01 UeteWon and
---
lufflatinLy Devices
No. of Ranges
No. of Air Cond. To—tal
Tons
No. ofAlerting Devices
No. of Waste Disposers
Rest m Numb-i—i Tons jXW
- --- -Re-a .
NO. Of Self-Conta
DetectionfAlertingDevices
No. of Dishwashers
Space/Area Heating JCW
mumpal
Lem 10- MI -1 0 Other
connection
No. of Dryers
Heating Appliances ICW
Secy0ty.45yste=—:-
No. of Watejr--
Heaters KW
Iwo_.—Of NO.
No. of Devices or Equivalent
Data Vtlrbg:
I
- Signs Ballasts
oi of Devices or Equivalent
No. Hydromassage Baftubs INO_
ofmotors Total HP
Telecommunications W55E.
No. of Devices —1 ent
OTHM_
AM& adawmar &WI rfdesb-ed. or as rrp�&_ bj, dw hrpecor
E Value OfElectical WO& Men mphied by municipal policy) of WV*=
Work to Start - — Inspections to be requested in accordance wM'hMC Rule 10, and upon compledoiL
]INSUP-AiNCE COVERAGE: UWess warved by the owner. 310 permit for the performance Of eltctncal work may woe unless
the licensee provides proofof liability insurance including -completed operatioe coverage or its sabstandal equivalemL 1'he
undersigned cer"es that such coverage is in force, and has embibited proof ofnme to the permit issuing ojffim
aV_CK0NF_ DiSMANCE)U BOND [I OTBM 0 (Specif3r)
I efffify, wider Ae paim andpenaWes ofpa*7, A& the Informatton on ffds aMficadon is &ue and complela
FRMNAK&Buddy Electric Inc. L1C.NO_- 12017 A
Licensee: Vincent . B. Landers jrSignaft.- LicNO-23684 E
qf4vn=bk MW "emno -in the ficeme monber &M) 2L`1
Address: 24 ftlante 1)r IT.Ancloyp �S. Tel. Nw-779
:7:757--T4 5 5
MA 0184 AIL TeL 1W
*Per XG.L. c, 147, s. 57-61, security work retlaires Departmm--t of Public Safety ��Jjceuse.- Lic. No.
OWNER. -S DWURANCE WAIVIPL I am aware *9 the Licensee dms not have the liability - CDveragenormally
Minired by lxW BY MY signature below, I hereby waive this requirernalL I an the (check Insurance
Owner/Ag011t one 0 owner [] owner's ageaL
Signature Telephone No. LPMZfiyTF".- $
r',o N, I o /q,�,
ADMicant Information
77se Commonwealth of Massachusetts
Department of Indushid A"itlents
Office of Investigations
600 Washington Street
Bosion, AM 02111
www.mass.gov1dia
Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/organizationandmduai):
Address:
City/State/Zip:
Phonek
r ;L '-
L t,
Am you an employer? Check the appropriate box: Type of project (required):
1. 0 1 am a employer with ��- 4. E] I am a general contractor and 1 6. New construction
employees (full and/or part-time).* have hired the sub -contractors
2.0 1 am a sole proprietor or partner- fisted on the attached sheet. 7. Remodeling
ship and have no employees These sub -contractors have 8. Demolition
working for me in my capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance COW- ksuranceJ
required.] 5. [] We are a corporation and its 10.[] Electrical repairs or additions
3. El I am a homeowner doing all work officers have exercised their 11. E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.E] Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
emplo�ees. [No workers' 13.0 Other
comp- insurance required.] I i
that oheelm box #1 must also fill out the section below showing their workene compensation policy information.
t whD submit this affidavit indicatmg they am doing all work and then hire outside conbactors must submit a now affidavit indicating such.
lConftactors 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.
lam an enWlowthaf isprovidingworkem'conWemutim btsurancefor nV evrJoyee& Belowistkepofivy andjob site
information.
Insurance Company Name: Pe e) Y) 42 /, ller-s
Policy # or Self -ins. Lic. #:_ OK-' Lt) / 3 e5-1� epo C, Expiration Date:/)// Id e
Job Site Address: City/StateMp:,
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
fint up to $1,500.00 and/br one-year intprisomnent� 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 coverap-e verification.
I do hereby cerafy wider the paws andpenakuN ofperjwy that tke infornsafton provided above a true and correcL
Phone#: 47 7k 9 7,5--- ZI-VYS
use only. Do not write in this area, tobe conrhted by Wor town offikial
City or Town: PermittLicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Departm6t 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
RENEWAL AGREEMENT
PRODUCER:
Penn Millers Insurance Company 0005351
SEGREVE & HAL`L INS. ASSOC.INC.
72 N. Franklin St. PO Box P 305 NORTH MAIN ST
Wilkes Barre PA 18773-0016 ANDOVER MA 01810
NCCI CARRIER CODE: 17027 (978) 975-1300
POLICY NO. PGW 1305280-05
PRIOR POLICY NO. PGW 1305280 04
ACCOUNT NO. 0003017108
1. The INSURED/MAILING ADDRESS CORPORATION
BUDDY ELECTRIC FEDERAL EMPLOYER IDENTIFICATION NUMBER(S).
24 COLGATE DR 042966854
N ANDOVER, ESSEX, MA 01845
*OTHER WORKPLACES NOT SHOWN ABOVE:
2. The policy period is from 12/01/2009 To 12/01/2010 12:01 A.M. Standard Time, at the
insured's mailing address.
6
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compen-
sation 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 our liability under Part Two are:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 100,000 each employee
Bodily Injury by Disease $ 500,000 policy limit
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed
here: All States except ND, OH, WA, WV, WY and states listed in Item 3A.
D. This policy includes these endorsements and schedules:
For MA
W� 00 04 14 WC 00 04 22A WC 20 03 01 WC 20 03 02 A
WC 20 03 03 C WC 20 04 03 WC 20 04 05 (6-01) WC 20 06 01 A
Total Estimated Annual Premium $ 2,949.00
Deposit Premium $ 2,949.00 Minimum Premium $ 278.00
Premium Adjustment Period: Annual Premium for this transaction $ 2,949.00
Premium to be Paid by: INSURED
Countersigned by
Authorized Representative
WC 00 00 01A Copyright 1987 National Council on Compensation Insurance Page 1
DATE OF ISSUE: 09/23/2009 Insured 0000.001
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