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Miscellaneous - 350 WINTHROP AVENUE 4/30/2018 (7)
Staple oidejS Date .... 4. -. Z. 4.- -0..? TOWN OF NORTH ANDOVER PERMIT FOR WIRING z ... .... �/ r/ -+V1 -r/e 0 7�?7 ..... ��e — This certifies that ..... ............. ? ....... R.E r:7 ..... ... ... has permission to perform ... .......... .... . ............... —ei ... 6 wiring in the building of ... .......... at .... ........... North Andover, Mass. Lic. No. . .......... ELECTRICAL INSPECTOR' Check # 8841 (fommonwea& o f Madaac4adetb Official Use Only cc�� ��Permit No. 2epartment ol.77 ire Serviceb — Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK \Il �N ork to be performed in accordance with the Massachusetts Electrical Code (ML ); X27 CMR 12.00 (PLE.�I.SE PRI.\ T I.\' IXA— OR TYPE ALL IA; OR:ILAT10:\t Date: Cite or Town of: To the Inspec oro >Vires: I3, :hi, appli�aron the undersigned 2,\n notice of his other intention to perform the electrical work described below. L.orttiun (Street & Number) Ot%ner or fenant ONN ner's Address Is this permit in conjunction with a building permit? Pw-posc of Buildinh Telephone No. &, l Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Lxisting Service Amps i Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters .Number of Feeders and Ampacih No. of Receptacle Outlets No. of Oil Burners FIRE ALAR IS a Location and Nature of Proposed Electrical Work: P Contnletion nl thv t"nllnwina Mn 1. mrn; h.. —,;'-d 1— ,1— 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 b Qrnd. ❑ grnd. ❑ ! o. o Emergency Lighting Batten" Units_ No. of Receptacle Outlets No. of Oil Burners FIRE ALAR IS No. of Zones No. of Sw itches No. of Gas Burners No. of Detection and Initiating Devices \i,. of Ranges " No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals F,—,umber Tons KNN' No. of Self -Contained Detection/Alertin Devices No. of Disimashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dr)ers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. ofWater ater Heaters _No. No. of No. of Signs Ballasts Data Wiring: of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Lstitnated \' aiue of F .- rica \Fork: (When required by municipal policy.) \Y ork to Start. 1% , Inspections to be requested in accordance with MEC Rule 10, and upon completion. iNSCRANCE C E'ER. GE: Unless %vaiN ed by the owner, no permit for the performance of electrical work may issue unless lite licensee prop ides 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 pen -nit issuing office. C -lFCK 0\E: INStRANCE ❑ BOND ❑ OTHER [I (Specify:) I certyi% under the pains and penalties ofpeijury, that the information on this application is true and complete. FIRy( �:k\lE: / � L _'r LIC.NO.: Licensee: p. 11 � c Signature IC. NO.: % %3 11 oi,-)bcuNe. enter ' e.Yen� t' in the lice .se nt be .li 7e. _ " itl+'/ ���! �/ 1✓) %�% i��l� "/ Bus. Tel. 10.. Add. ess:, �j[ r , ,; _ Alt. Tel. No. 210.1, 'Per M.G.L. c. 147, s. ; 7-C 1. security work requires Depa Hent of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally 100u11'6; b•, il—m. By my signature below, I hereby,,vaive this requirement. i am the (check one) ❑ owner ❑owner's agent. (.honer Aint Ji�rtat,n•c _______ Telephone No. I PERti7IT FEE: $ A Date......:..'' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. a f G 2 / 5 C�4'(/ ............... �..........., ............................... has permission to perform ......... �� �i � �G�� TAY,....5",Fl .ry . ........................ . wiring In the building of ..... F.....�t,/ .... ! N% ...... , North Andover, Mass. Fee ...Z/ 0 6.... Lic. No..ys" C .. y ................................. 3CTORM ELECTRICAL Check # �C1a6�S - .... 7743 l.ommoawea& o f Maddackwattd Official Use Only cc�� ��]] C� Permit No. `% L� 3 2epartment of ire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] 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 INK OR TYPE ALL INFORMATION) Date: 10-17-67 y City or Town of: 05 %2 i Fk x)10 31>a 0ef-- 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) 5- 4 W i r,� —, H-K.ov S Owner or Tenant 1 ✓1 Q + -ee'r —�-kc NK -)a ave -,z Telephone No. Owner's Address 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 e Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ��5 �1� ;yt ch �>� t,t►�� ©Iyr,�T- A- Com letion of the ollowin 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 K -VA No. of Luminaires. Swimming Pool Above ❑In- ❑ rnd. rnd. No—.of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I ..", umber Tons .."....... "" W "' ..'"'."." o. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Municipal ❑Other No. of Dryers Heating Appliances KW <ecuri S o. o evices 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 OTHER: 6 c.0 4 _ 1 5 -3.5 - Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: [' / SC/. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAG t : 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 Q BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perju�rythat the information on this application is true and complete. FIRM NAME: "AbT , ►^ t to Sf-r V �Ci-S LIC. NO.: J-15 C. Licensee: mar 1L V�Y-(p Signature `> ';��_ 1. `i LIC. NO.: (Ifapplicable, enter "exem-t in the hcen u"r line.) Bus. Tel. No.: b 0 Address: 1 3't i—i h 7c --,4V ,4 . p � t � S, Ili U 3 0 q-% �y Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WADER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature'belo�v, I hereby waive this requirement. I am the (check one) ❑ owner ❑ ow er's agent. Owner/Agent PERMIT FEE: Signature Telephone No. FOmm CDT p1 cn< �roxo 66Orcoi j -q V Vs co > 1 CD (DD w CO N a M w cn r- 0 0 M z cn m 00 O cn � om.Z co D-t -0 to o = r Co <D Q m D N H w is Co O M rD 0 v c N ai m� m o z ; p mm n o o � -zj m O 3 3Ln y o m Li® c� Cl m < o , n z 3 D M ca v m m o � O ADO v ; M 0 Cf) D m M m M n D O 3 m +a n M � o /o .n C40 3 coco o ;u0 _ -f'n O V N W a w cnwa m�M m �m Z o mm m a m N -i r- V "C In .<;u .�3 tim I-qO gr .� D �� 0 oma O=> -ns wH o m �z NM n znc m O D (n = m O U) -i Z (n o H N �! n w ( � z nc c m o . LVI N M I (n Signature L FOmm CDT p1 cn< �roxo 66Orcoi j -q V Vs co > 1 CD (DD w CO N a M w cn r- 0 0 M z cn m 00 O cn � om.Z co D-t -0 to = r Co <D Q C0 =S c C N H w is Co O M rD 0 v c N ai m� m o z ; p mm n o o � -zj m O 3 3Ln y o m Li® c� o m < o , n N D M ca v m m o � v c� Cf) D m M n D r r n M z -f M M coco w A A - V N W w FOmm CDT p1 cn< �roxo 66Orcoi j -q V Vs co > 1 CD (DD w CO N a M w cn r- 0 0 M z cn m Location���"°"' No. r) e-), -e / Date e%- 16-1 MORTq TOWN OF NORTH ANDOVER F R L I ; , Certificate of Occupancy $ ctBuilding/Frame Permit Fee $ sAwus Foundation Permit Fee $ Other Permit Fee - $ y� TOTAL $ n� Check # r 2a4���. v `Building Ins , ctor 0 0 O N 1 Q H � cis C 4.6o d � U A a M Ir Z w 0 O a 0 V z J Q a S = a � a 0 F c zLL c 0 W z a Z O W o m .a N m � Q in w z 0 bl l Co m c E c •- >. ca = L Z c W cu - U c 0 cu C I - �� 4 O 0 � m a �c� am a�QwcN� -oma o Qc.o a, _�•E L 3 -Q m � c*o.o cu ->C, a L+ lA o 0 L3O EJ cn c ot c U am)c V >+ m e L- U) - C13 U) O U U a) .N CO L'm U NL c a) L [2.� me o4 o o ac c cu ��v, aa- m c co LO U >+_ c E(u cacw.mcao a) c a) C N :t-- ._c o f *tn c UO aE c N 0 0 L U L o >.L -Cc aE U c a cu U Q- m a) .cQ Ems La> ai c`o a) c o Ea)o0-a) c Oc 0 L O L L- d Za�w(naLov�,ca N c LM .N rn c •II c m i a) m cu a) O U m U m c te.D a, ! UO N c O U�a)aO,� Lmn.� 00 a o a� �amcnE u,Q a�L ma.rnrn Lrn.�v)Lc L0 L 7 O m L o z w q c a� m N W C y_ (D O C L Q) 0 Qno ,- 0 O c Y J m m -0 U 'U U m O O r U m 3_1 a) m U) o Q aL i O 0 � m a �c� am a�QwcN� -oma o Qc.o a, _�•E L 3 -Q m � c*o.o cu ->C, a L+ lA o 0 L3O EJ cn c ot c U am)c V >+ m e L- U) - C13 U) O U U a) .N CO L'm U NL c a) L [2.� me o4 o o ac c cu ��v, aa- m c co LO U >+_ c E(u cacw.mcao a) c a) C N :t-- ._c o f *tn c UO aE c N 0 0 L U L o >.L -Cc aE U c a cu U Q- m a) .cQ Ems La> ai c`o a) c o Ea)o0-a) c Oc 0 L O L L- d Za�w(naLov�,ca N c LM .N rn c •II c m i a) m cu a) O U m U m c te.D a, ! UO N c O U�a)aO,� Lmn.� 00 a o a� �amcnE u,Q a�L ma.rnrn Lrn.�v)Lc L0 L 7 O m L �, 0 w d W U U w c0 O z J J_ z 0 Q U' J F- CL a Q a � o o LL w Z 0 z Q o z hi c m } m m 3 -v O O CL 3 a ccu Q� s O �a) > E 0 c z _rn aD } w �, 0 w d W U U w c0 O z J J_ z 0 Q U' J F- CL a Q a � o o LL w Z 0 z Q 08/01/2007 11:38 9786826473 Q P I MINCO PAGE 02 w W � w 1111. tu U m r r- al w r- r- 3 Q CL lu 1111. ` 0 • m o 0 , 11 Q P I MINCO PAGE 02 .0 -In M w U to Z W uJ �0 w 1111. tu U m al w 3 Q CL o Ix 1111. • �I�1 11 • 11A i111 1111 .1■1 .0 -In M w U to Z W uJ �0 w tu U m al w 3 Q CL o Ix s C O O O O O M O C N J N rlN N M L O 2 O N M d' r N f0 U G a rn N O N O O N N 00 N O "a c a F - ^L^`` AWA` W C N N >G a U a t a c T .N a `m 0 c Q s H O Cl O N m s O � O � c X N 3 M N 0 d) B .y c d' c O rn It w M LO 0)L c J O O LO O U) d' t O a) 2 M LO r (fl r N N U Q v LO O M P- C O N N OD rr Q a c rn .N C c 0 m c a o a om- N --0 CN H O � C X a �o 0 N c 00/02/2007 10:31 9785212192 THESIGNCENTER PAGE 04/04 AiAW Q, 2007 To Whom It May Cone Please accepti that lettex as authorization for The Sign Ccnter to ant opt our behalf for obtaining sign permits for Wine and $eei� at 7'lle Andoven located at 360 Winthrop Avenue, North Andover, MA - If you have any quesbons regWing the above noti£icatlon, do not hesitate to oontact Me at ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID D DATE(MMIDD/YM) INSIG-1 12/21/06 RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE D Banknorth Ins Agcy Inc (SF) HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Q. Box 9040 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, pringfield MA 01101-9040 'hone: 413-781-5940 Fax: 413-733-7722 INSURERS AFFORDING COVERAGE INSURERAST PAUL TRAVELLIlS CONSAAIES ENAICSURED Inc. INSURERS Technology insurance company 6insigKia INSURERC Vit'l Union Fire Pittsburgh PA 1445 DBA The sign Center 40 Orchard Street INSURER Haverhill MA 01830 INSURER E OVERAGES 'HL :."I. �L IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANI Ht`JOIRLMENi It RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MASOERAIN THE. INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH rA -;L: AL uPEOATE LIMIIS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS - -..___.__..._ R, ODL R INSR TYPE OF INSURANCE POLICY NUMBER _ OATS (MM/DD DATE (MM/OD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 � X :OMMER(IAL GENERAL LIABILITY 6605858C38A 12/12/06 12/12/07 PREMISES (Ea occurence) $ 300000 CLAIMS MADE uFx1 OCCUR MED EXP (Any one person) $ 10000 HGEN'L PERSONAL 6ADV INJURY $ 1000O00 GENERAL AGGREGATE $ 2000000 AGGREGATE L IMIT APPL IES PER i PRODUCTS •COMP/OP AGG $ 2000000 POLICY PRO JECT LOC AUTOMOBILE LIABILITY UTO BA8642C340 COMBINEO SINGLE LIMIT 12/12/06 12/12/07 (Eeaccident) $ 1 00 0,000 WNED AUTOS ULED AUTOS BODILY INJURY (Per person) $ AUTOS BODILY INJURYWNED AUTOS j (Per accident) $500PROPERTY lision $500 DAMAGE (Per accident)BILITY AUTO ONLY - EA ACCIDENT $ TO OTHER THAN EA ACC AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY F._ _.. EACH OCCURRENCE $ 5,000,000 IX •?CQIR I CLAIMS MADE EBU3948704 12/12/06 12/12/07 AGGREGATE $ 5,000,000 F....1 DEDUCTIBLE $ X RETENTION $10,000 WORKERS COVVC MPENSATION AND X TORY LIMITS EMPLOYERS' LIABILITY IANYPROPRIETOR/PARTNERIEXECUTIVE TWC3124578 ER 12/12/06 12/12/07 E.L. EACH ACCIDENT $500000 JFFICEPrMEMBEPEXCLUDED� II yes. Oe scn De un0er EL DISEASE EA EMPLOYEE $ 500000 SPECIAL PROVISIONS )010W E L DISEASE • POLICY LIMIT $ 500000 OTHER Garage Keepers 6605858C38A 12/12/06 12/12/07 Garage Legal Liability Keepers $100,000 CRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS provide evidence of insurance. (TIFICATE HOLDER CANCELLATION GENERIC -0111) ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN In S i gn i a , Inc . NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Oa? ` he Sign Center IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 40 Orchard Street Haverhill MA 01830 REPRESENTATIVES. TD Banknorth Ins, 'RD 25 (2001/08) ac. © ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 e Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers u ders/Co plicant Information ntractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: l . ❑ I am a employer with 4. WI am a general contractor - 2. ❑employees (full and/or Part-time). I am a sole proprietor or and I have hired the sub -contractors listed partner- ship and have no employees on the attached sheet. t These sub -contractors have working for me in any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We are a corporation 3. ❑required.] I am a homeowner doing all and its officers have exercised their work myself. [No workers' comp. insurance right of exemptibri per MGL C. 152, § 1(4), and we have required.] t no employees. o [No workers cora I.- -- n Type of project (required): 6. ❑ New construction 7. ® Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs P• urance required.] I 13 0 Other 'Any applicant that checks box # I must also fist out the section blow showing their workers' compensation policy mformat�on t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their wnrL-.—, r _ such. •• »•• -•••Y.-yer snag "pro workers' compensation insurance r , ..., 1—vi isuon. injorniation. for my employees. Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lie. #:_�G�Q�90� Expiration Dater Job Site Address: Attach a copy of the workers'compensation policy declaration Page rtthe�Policy (showing Rg( g number and expiration 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,a as well as civil penalties in the form of a STOP WORK ORDER and a 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 fine Investigations of the DIA for insurance coverage verification. r,a,. r.....a --• - .Y ••f y Wnaer fle pains and alties Of, erjury that the iture-�,�information provided above is true and correct iture-c,/wli //� OfJ?cial use only. Do not write in this area, to be completed by city or townofflciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical rncnn....._ 6. Other _ Contact Person: Phone #• Received Fax : Jun 28 2007 9:31 Fax Station : Com -Con Contractors Inc D 2 •' From: Noreen Dandurant At: Hub International FaxID: HUB International Ne To: Doris Date: 6282007 09:27 AM Page: 2 of 3 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID N DATE(MMIDD/YYYY) COMME01 06/28/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HUB International New England HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 299 Ballardvale St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington MA 01887 GENERAL LIABILITY Phone:978-657-5100 Fax:978-658-9185 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Ohio Casualty Group A INSURER B: Guard Insurance Group Com -Con Contractors Inc INSURER C 13 Sun Lane Pelham NH 03076 INSURER D: INSURER E: MED E.`(P (Any one person) $ 10000 RIGIV1 :I:L'lC1 A.7 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. AGGREGATE LIMITS SHO1Nt•l MAY HAVE BEEN REDUCED BY PAID CLAIMS. IMM LTR ZuL INSRC PE OF INSURANCE POLICY NUMBER POLICY EF ECTIVE DATE (MM/DDIYY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COtAMERCIALGENERAL LIABILITY CLAIMS MADE X❑ OCCUR BLO 53435116 01/05/07 01/05/08 PREMISEs(Ea occurence) $ 100000 MED E.`(P (Any one person) $ 10000 PERSONAL &ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $ 2000000 POLICY PROT LOC JEC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS. MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER(EXECUTIVE CONC702957 04/21/07 04/21/08 X I TORY LIMITS ER E.L. EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYEE $ 100000 OFFICERIMEMBEREXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 500000 OTHER A BPP & TOOL BKO53435116 05/28/07 05/28/08 BPP/Tool 30000 A RENT/LEASE EQUIP BKO53435116 1 05/28/07 05/28/08 EQUIP 100000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Subcontractors -Job: Liquor St,350 Winthrop Ave,No Andover MA CERTIFICATE HOLDER CANCELLATION No. AND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Attn : Building Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR No. Andover, MA 01845 REPRESENTATIVES. ACORD 25 (2001/08) 0 ACORD CORPORATION 1988 Received Fax : Jun 28 2007 9:31 Fax Station Com -Con Contractors. Inc o . 3 ' From: Noreen Dandurant At: Hub International FaxID: HUB International Ne To: Doris Date: 6/28/2007 09:27 AM Page: 3 of 3 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. Com -Con Contractors' Inc 13 Surrey Lane Pelham, N.H. 03076 CONTRACT SUBMITTED TO: R.M.D. Inc NAME J.. Pasquale ADDRESS 881 East Street Tewskbury, Ma. 01876 PHONE NO, 1-978-851-0200 SHEET NO,1 DATE: 6/27/07 WORK TO BE PERFORMED AT: ADDRESS 350 Winthrop Ave. North Andover, Ma, 01845 DATE OF PLANS ARCH. Oratovsky We hereby propose to furnish the materials and perform the labor necessary for the completion of Demising Wall and Install New Glass Storefront All materials is guaranteed to be specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workman like manner for t he sum of Thirty thousand two hundred fifty three dollars Dollars ($30,253.00 _) with payments to be made as follows. 50% down with 50% upon completion Any alterations.; or deviation from above specifications involving extra exist will be executed only upon written order. and will become an extra charge over and above the contract All agreements contingent upon strikes, accidents, or delays beyond our control. It shall be a default if 'payments are not made as set forth above and: A Contractor may withdraw its men and materials and equipment from the site. Any cost associated with such withdrawal and return shall be considered an approved extra. B. All attorneys' fees, expenses and cost of collection shall be added to the contract price C. Any delinquent amount shall accrue interest at a rate of 18% per annum Respectfully submitted, Per Com -Con Contra or's inc. ACCEPTANCE OF CONTRACT The above prices, specifications and conditions are satisfactory and are hereby accepted You are authorized to do the work as specified. Payments will be made as outlined above, The undersigned personally guarantees the obligations set forth above and all modifications thereof Date - Vude- 2d, z1v 7 Signature _ _� Date......$..ZZ a % °'t"`° :•�"a TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 50 , This certifies that .........t 't.�.aK.L.! /. ��-� ............ ............. ........................... has permission to perform ....................1'. T[J !�........................................... wiring in the building of . WI ME. 14.p...... .at �b w..�rt1%!7�.G. n` , ..... ................. No h�r Mass. ... ........ .... ........ . �!2 Fee ...I Z 5......... Lic. No. .. ..................... _. ........ ELECTRICAL INSPECTOR Check # 2? C�� 7590 E ,N kk b' Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. *76-1 t�) Occupancy and Fee Checked tev.1/07] (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 INK OR TYPE ALL INFORMATION) Date: o - 22 -01 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigRds notice of his or her intention to perform the electrical work described below. Location (Street &Number)„Le O t ro yyeoP AveLtd C3�= MA21� T S k Owner or Tenant U3F o e A N p ���- aT TA -z` A N ®AV --- 25 Telephone No. 9 612-8'627 Owner's Address SZO W %N %2tQ-0 P AV Is this permit in conjunction with a building permit? Yes I[[ No ❑ (Check Appropriate Box) Purpose of Building OCW \1"IyoC 4Vrc b* - u p Utility Authorization No. f° Existing Service Amps / Volts Overhead ❑ l� 4,00 Amps i2.0 IZOY Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters Undgrd 9 No. of Meters �1 \ - - A m motion oftho f ll..,.4— #..1 l ,. 1 � t_. a__ v_____._ �..,• Co No. of Recessed Luminaires -- - No. of Ceil: Susp. (Paddle) Fans ,,.0 — -U&m” Uy mt:lrw e-'ur uj rrtres. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In ❑ rnd. rnd. o. o Emergency ig ng Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALAI4MS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges No. of Air Cond. os Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers No. of Water �, Heaters Heating Appliances KW No. of No. of Signs Ballasts Systems:* Security No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f Electrical Work: 1 `Z i UUCP (When required by municipal policy.) Work to Start: ' ao Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VERAGE: 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 Co ffi rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K- BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalttes ofperjury, tha( the information on this application is true and complete. FIRM NAME: 1(i)AYYM4CA (;Z (,2 % C �.1 e t 11 S� lY1e lit)• rY)X LIC. NO.: 6 k Licensee: K.A �q,r,,� �yae,A Signature LIC. NO.: (If applicable, enter "exempt " in the lice a nu er line. /� _ Bus. Tel. No.: Address: '� fe GA f - 41•(r� ►' l� 0 ( �/ Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. 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 Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 c i www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): MA M M' 01 A G 1 e ck n cA 1 Address:_ 0Q r 6L City/State/ZiP:M14VnLltjj 01 ?`(4 Phone #:. 02 L -� A,reyou an employer? Check the appropriate box: Type of project (required): 1 I am a employer with 1 4. ❑ I am a general contractor and 1 6. D New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• P9.Remodeling ship and have no employees These sub -contractors have S. Q Demolition working for mein any capacity. [No workers' comp. insurance workers' tromp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition required.] officers have exercised th their 10. Electrical ❑ repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL I III Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.[]Other comp. insurance required.] -Any applicant that checks boX ii I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: ' � (Af k � Policy # or Self -ins. Lie. #: 0 a G Expiration Date: Job Site Address: S i t.5 �(,U (� V 1L (� . (� tJ h City/State/Zip: �. Q cI lio 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 $4500.00 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. 1 do pains yd�enalties of perjury that the information provided above is true and correct loJ 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions I Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence -of compliance with the insurance 'coverage required." Additionally, MGL chapter 152, §25C(7) states' Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy workers' compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also 'be sure to sign and date the affidavit. The affidavit should be returned to the city, or town that the application for the permit or license is being requested, nottthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia a" This certifies that Date. g.�I JA . TOWN OF NORT)#'ANDOVER PERMIT FOR PLUMBING has permission to perform ... cA...44 ................. plumbing in the buildings of ..'??.nt < .l. �...L.! f.......... . at ... .. !t.h .��!E � �'............. .�N-oorth Andover, Mass. Fee .. •/ I(.... Lic. No.. ....... PLUMBING INSPECTOR Check # 3 T 7 Y 7496 • I (Type or print) NORTHAND Building Location MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING .R, MASSACHUSETTS / "/ I}/� /' �Q � �/C)�,. t-I d'��O p Owners Name Permit #_ t(56 Amount Type of Occupancy 0 y" T New rl Renovation Replacement Plans Submitted Yes No FIXTURES i i ►,V (Print or type)p j Check one: Certificate Installing Company Name I T�7^� ►Vl I 1` i rA Corp. Address r Partner.' Business Telephone _a o q Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of instionce coverage by checking the appropriate box: Liability insurance policy Other type of indemnity El Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusqo. State b' ' ode and Chapter 142 of the General Laws. 00 By igna o rce er , Type of Plumbing License Title Z 7?{ City/Town License MEN= Master Journeyman ❑ APPROVED (OFFICE USE ONLY L�1 Date .. �* NORTIy Of.,'o ,c1ti °p TOWN OF NORTH AMID -OVER o=4 PERMIT FOR GAS INSTALLATION This certifies that ..4., 41 ...... r, .1--R has permission for gas installation . .. .�: �.f=, ; in the buildings of .. %!J:? .�. r ,�? �, , ,... . ... . ... . ... . at ... 35. ' -P. 1, .i.*( . /?/..... , , North Andover, Mass. Fee. Lic. No.. t .4 . �..• GASINSPECTOR Check # 7)- 6135 )- 6135 L ��� dKir��oo �I�z.o� MASSACHUSE'T'TS UNIFORM APPUCATON FOR PERM TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations V 0YV1 Vit P V10 P CA 1 Owner's Name New ❑ Renovation 1 Replacement ❑ Date ld _/0 -eOV -7- Perin i Permit # Amount $ Plans Submitted (Print or Name C ness 0 Name of Licensed Plumber or Gas Fitter Cbhk one: Certificate Installing Company Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes® No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Ep Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State G ode ,�r(d Cter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber r Z7`f Gas Fitter License um er Master 13 Journeyman vi O zw a H z Q Z °o w� w x u w x W d OH > d w d x �+ a g W Ca E• x z w > z x E, d w o m > z w o z U v, a z � 3 a a t� ° a > % O w tx- SU B -BASEM ENT .da A a F o BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or Name C ness 0 Name of Licensed Plumber or Gas Fitter Cbhk one: Certificate Installing Company Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes® No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Ep Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State G ode ,�r(d Cter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber r Z7`f Gas Fitter License um er Master 13 Journeyman Date.....". -!7.7 ..... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that.................................A--.r,4-. .:A�� ...................... has permission to perform . wiring in the building of ... .`...................................................... at.................. , North Andover, Mass. r Fde................... -t ........ Lic. No. �. �?.�.....:. E�cre►�cuNs� (, i°1°SR Check #— Y 7495 I SOWLC C- dk 7-�P7--w 17" P;I� F -e7 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked Rev. 1/07] (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 INK OR TYPE ALL INFORMATION) Date: 'I 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) �,,p W 1 9�j aUP f r Tenant 91`7 A flaE�'i�Pe �iZl.(s Telephone No OEwner Address -� .S 1%-,- S7 Is this permit in conjunction with a building permit? Yes i❑/ Purpose of Building �SflAl C11 ZIUA S Je-(�F Existing Service Amps No L_f (Check Appropriate Box) Utility Authorization No. 553 S Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Z2-5 Amps 12a / 20B Volts Overhead 0 Undgrd ❑ No. of Meters Number of Feeders and Ampacity JT z.S� /" fi1.uM - l 1 31 o -�u1'1 Location and Nature of Proposed Electrical Work: _,� _ _ _ _ - 0" -�- �rr+r�mnr�►n .A Att&Cn adamional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �� (When required by municipal policy.) Work to Start: •°?.z_o7 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 L? BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Uw QJ C,!F-N 1{3 Al, EkU etq) i tc LIC. NO.: m2 L4 Licensee: EN,9V�k i („ M _ Signature,�2,n,\— .4 N� LIC. NO. (/f applicable, enter "exempt" in he lice se nun erli,�e,� Bus. Tel. No.:!) •'tt6 Address: a)� a1� Alt. Tel. No.: a *Per M.G.L c. 147, s. 57-61, security Ark requires Department of Public Safety"'S" License: Lic. 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 Signature Tele h N PERMIT FEE• C pone o. '7701,17P,617,17,170/ cnewtivwtrtg tuUte may De waived vy the Inspector of Wires. -OT- No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above _EJ In- El. o mergency Lighting rnd, rnd. Baotter 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 InitiatingDevices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number Tons K .._. No. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No o ater No. o No. o No. of Devices or Equivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: SV i;kl .A Att&Cn adamional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �� (When required by municipal policy.) Work to Start: •°?.z_o7 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 L? BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Uw QJ C,!F-N 1{3 Al, EkU etq) i tc LIC. NO.: m2 L4 Licensee: EN,9V�k i („ M _ Signature,�2,n,\— .4 N� LIC. NO. (/f applicable, enter "exempt" in he lice se nun erli,�e,� Bus. Tel. No.:!) •'tt6 Address: a)� a1� Alt. Tel. No.: a *Per M.G.L c. 147, s. 57-61, security Ark requires Department of Public Safety"'S" License: Lic. 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 Signature Tele h N PERMIT FEE• C pone o. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s< www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual): F � t2'TqIC' Lb 17N Address: CJ f i, MS" D S T, City/State/Zip: ), y -uc �),2_(�1 a 1 8;51 Phone #: °f �� - '�3�'�l62. , Are you an employer? Check the appropriate box: 1.0 I am a employer with 1f Z 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7.D -Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. nn Insurance Company Name: hN1;kT._\` Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 36'6 )'of -0 City/State/Zip: 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Siunature: Date• 4 53•-1 &2-L C 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 #: w O 0 W W cz O v u o a w or. a neo U ro w A. to a°' w a w w W rx cn 0 w C7 w w a w c ra z co o cn =o a O i :ice ✓� IMO V O O O 4D `,Sir � • • E a Y o c � 3 4 0.2 Y � �_ sir ;gyp., d y 41 ° 47 C �O� m o *** 16 O z WA%ts cm a % �; GO 99 L y r.+ Of mcm CL 16- ID - bJ m m CC cm's a v, W d C = •p F� • �' �m O� m fp.1 N O O O � Z Of Q O y O C •p = m CL : N � a o COD •y uiCL= O C Z �u .E "m C.3 m COO O. .0 C.3 O= H = waSm x O9 -L, co ■ L � v z CL °' O CO) � C I cm ca O ■� ca p 'C O _h O O �E m m CD 0 CD CL ~_ CD o� �3 0CDas 0 ca � o�Q o -6-0� c eccc V c Z CD CD V y C C C c CO) 0 LLI LLI U) oe W W W 0 Board of'Building Regulations and Standards � Construction Supervisor License o: License: CS 55991 r Birthdate: 1/8/1950 ! Expiation: 1%8/2009 Tr# 7849 f Restriction- 00 RICHARD J LEAVER ' `r S 16 BOWERS AVE TYNGSBORO, MA 01879 ~ '' Commissioner,