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GF NoarH,~C
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ...............................................................................................................
has permission to perform
...........................................
wiringin the building Of.....................................................$......................................................
at .............. . ................ ..............,North Andover,Mass.
...... . .....................................
Fee.30:�" ........Lic.No- 2.aq2-n.................................................................................
ELECTRICAL INSPECTOR
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BOARD OF FIRE PREVENTION REGULATIONS rp
1/071 (leave blank)
APPUCAT[,C)NJ FOR PERN,'HT TO WORK
All work M be,performed in accordance wi:h !1!c
j
Cod:.(MIE ), i27CM-R 12,0,
OR UPEAILL PVFOR44AT101 D e:
City Or Town of: 'To th,o o
By this application the LITICICI-Sl'
af��Claq�'Ci�-oiic'-ORis or her intention to 1,
c' 'v�r.. described
Location (Street& Number)
Owner or,Tenant w�
P 1--y TclephonTelephone 'o
ie
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is this perillit ill conjunctio- LT
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Purpose of Buildin, tilitv Authorization No,
Existina Service
h /QG A.mlis /D0j_4ybvolts Overhead
New:Seriice
- - ] Nn. of Meters 15-
j( --I— —
Fil p S jK.v 0 1 rs Overhead ;e r If-'-��i d Undgrd O. of M]eters
Number of Feeders and Ampacity-
Location and Nature of Proposed Electrical `'Vo—rk: —V410 � --- ---
-- 1> �'w j r�v_v__ �_rcu�_ -- R ode L , SPM?A
410 ?Ak LA)t
NO. of Recessed LUMLJN12i!'rS stem
JN;o. of
JN"(). Of Ceu.--Susp. (Paddi�) 'F�ris
J
jr2rfsfo�rmicrs I
No. ofLL1FT)iflRjre Outlets INa. of Hot Tubs 'Gcn�rators
F)ON
—No,-o—fL-ti r-ri i-n a i i-e—s — A. 11\0 01 mlll-,Jcn"'�'v
i.swimming Pool
d. E'j
Ba(.ten, I n its
No. of Receptacle Outlets
No. Of Oil Burners
lNo. of Zones tiL
No. of Switches "N v- of Gas Burners No. of'Detection all
11ii(iPtiria Devices
No. of Ran(T. OfAir Corld.
Toils No- c-1 Al-ardn.- Devices
Mons I
i.-No. of Waste Disposers ............................ .......... "i I fie
Devic.-
Nu m b,
o. of Dishwashers Heauilia 11"-W
Connection
No. of D rvers Heating
7-)
F
C-,,s or 31
N o. C)I N7?T N1 0.
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Si2lis
'fcs Or a.l.fit
No. Hvdrcjnna_sage Bathtubs
IN 0. of Motcr-s [-'P
No. Devices or
OT
ITER: R-P)a ccc4 ol\,j 54,�1 co
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--l-riatcd VAc ofElectrical VV-D7* by policy.)
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Address:'
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i c q if ir--d 'Iby ';--v. R my sig-at-wre below, -,�by V.:-:
0 N),n c r/A ge ii r Ey y' '
Siariature,' No.
.1'he Commonwealth ofMassacliuse
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= Department oj'Indus7f•iaj'4ecident'
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Coag 1 ess Stl"eet, Suite.100
Boston .Uf)(
02-114-20.17
www.mass'.gov/dia
NA'orkers' Compensation Insurance Affidavit: Builders/Contractors/Glectr•icians/Plurubers.
A u)licant Information TO BE FILED WITH T..11E.PERIVH TTING AUTHORITY.
Naine (Business/Orgarlizatiou/Individual): -n-- --� Please PI:int Legibly
Address:_ �j�
_City/State/Z,ip: 111'--
._._ ___s`_.—.-'--:—���=—�•-�%��sI IlOIle f�' `� Olt l� __ I
Are yp an employer?Check the appropriate box:
amaemployerwith , Type of project(required)`: —
�( —employees(fill]and/or part-time). r
2]I am a sole proprietor or partnership and have no employees working for nie in 7• 0 New ConstTuCtion
3.L any capacity.(No workers'comp. uisuiance required.] 4. ] R.modeling
II am a homeo%sarer doing all work myself[No workers'comp.insurance:required]t
9• EJ* Demolition
4.]1 am a homeowner arid will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or arc sole 1 �� Building addition
proprietors with no employees. I I•(� Electrical repairs 01'addltiOns
5.r t am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12' plumbing repairs Or additions
These sub-contractors have employees and have workers'comp.insurancc.t
13-[�Roof repairs
We are a corporation and its officers have exercised their right of'exemption per MGI,c. _
152 1�.[-�Other
§1(4),and we have n i employees.[Noworkers'comp. insurance required.] ---- --
'Any applicant that checks box tl must also fill out the section below showing their workers'compensation policy information.
Homeowners who subniit this affidavit indicating they arc doing all work and Ihcn hire outside contractors must submit anew affidavit indicatin_;,.len.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whedici or not those entities;ave
employees. If the sub-contractors have employees,they must provide their workers'romp,policy munber.
I ant an employer t/iat isprnvid[ng workers'compensation insurattre for ary entpinyees• .I�e/uw is t/--te �o[1t1;a)td�o[�site----
In fortnat[orr.
Insurance Com an44-
P Y Name: t
Policy#or Self-ills.I,ic..#: _ -� -------- -----
-�'LI (__>t_t� C'' Exp iration D C r
ate:__.���_•� _�%---
Job Site Address:__L (�Cj � cityj -
Attach a Copy of the workers' col-ntpe-nsalion policy declaration page(showing /State/7_,i j�' - /
Failure to secure coverage as required under MG.] c. IS)• 1 ti ( b the policy number and expiration date).
and/or one-year imprisonment,as well as civil penalties in the for n c f a STOP WOR.K.IORDER.arid le ya fine of ti ne UP to
i)to 1S250.00 00.00
—day against the violator.A copy of this statement may be filrwarded to the Office of Investigations o:P the DIA for lost i ce
a
coverage verification.
Ido het eGj1,1,'r'ifyLd8r t[re ns andpenalties ofpetjuiy that the iifottnat[onpr vv[derl above[s b tte ant[correct.- -----
Sirrnature:
Date:
Phone s�i__�7__�,�n� � •'� C�_ -
Official itse only. Do not write in th[s area, to be completed by city or town official. -- -------�
City or Town:
--_.-- Permit/License it
Issuing Authority(circle one): --------- -------
I. Board of health 2.Building Department 3. City/•Town Clerk 4. Electrical Inspector. i. Plumbing Inspector
fi.t)tI1Cl'
Contact Pei-soil:
_ ------ -- --
07/01/2015 09;21Neil & Neil Insurance Agency (FAX)14137316629 P.001/001
I
DATE IMMIODIYYYY)
ACOR CERTIFICATE OF LIABILITY INSURANCE 07/01/2015
THIS CERTIFICATE 18 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 certifloats holder Is an ADDITIONAL INSURED,the polloy(les)niust be endorsed, If SUBROGATION IB WAIVED,eub)ect 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 e.
CONTAPRODUCER Neill 8 Neill Insurance Agency Inc p 0Ne David Jerry.
882 Riverdale Street (413)732-4137' ,(413)731-8828
West Springfield,MA 01089 ADDRE • v
IN A' AFFORDING COVERAGE NAIL 0
c E , State Auto Insurance Company STA
INSURED Michael Farelll Electrical E Acadia Insurance Co; 31326 .
9 Applewood lane N
Methuen,MA 01844
bU ER 4( —
N
INSURER F I
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 TWE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS_SHOWN MAY HAVE BEEN REDUCED BY PAID'CLAIM3.
INSR TYPE OF INSURANCE POLICY NUMaaR M I M LIMITS
A GENERAL LIABILITY SOP2746517 0811012016. 08/10/20`18 EACH OCCURRENCE ! 11000,000
DA I TO RI7W
COMMERCIAL GENERAL LIABILITY MEMO,
ddIEM b 60,000
CLAIMS-MADE p OCCUR MED EXP(Aily one croon b 5,000
PERSONAL BAOVINJURY = 1,000,000
I3ENERALA0GREOATE $ 2.000,000
GEN%AGGREGATE LIMIT APPLIES PER: PRODUCTS-CCMWOP_AGO ! 2,000,000
POLICY Ll
J&
LOC b
AUTOM091La LIAEILITY
ANY AUTO BODILY INJURY(Por Amon) S
AUTOS ED AUi0BUL80' BODILY INJURY(Per eWdanq S
N
HIM AUTOS
ON-OWNED 6 AUTOS + b
UMBRELLA LIAR OCCUR EACH OCCURRENCE b
RXCEESUAR HCLAIMS-MADE A0 RF-0AT8 S
060 RwreNnori! b
COMPENSATION WC-20-20.001461.08 03120/2018 0312012DIG
AND AMPLOYaRS'UARI'-ITY
ANY PAOPRIRRORIPARTNERhrX?CUVIVI• YIN6.L,EACH ACCIDENY 41100,000
OFFICaRIMEMEER EXCLUDED( N 1 A
DISEASE•EAEMPLOYEE b 100,000tMinde a ryInNNdIt oeiibouner
s ELDISEASE.POLICY LIMIT b 500,000
RIPTION
QF
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ANICh AOORD 101,Adtlillantl RSmerki SOhadule,H more spur,IS required)
Faxed to: 878.682-1480
I
CERTIFICATE HOLDER ± CANCELLATION
SHOULD ANY OF TH6 ABOVE 068CRIDED POLICIES BE CANCELLED BEFORE
Town of North Andover THF. EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1800 Oagood Street,Building 20 AOCORDANCE WI E POLICY PROVISIONS.
Suite 2035
North Andover,MA 01845 AUTHORIZED REPREaNTAW9 ,, e
019882010 ACORD C PORATIO"rights reserved.
ACORD 23(2010/06) The ACORD name and logo are registered marks of ACORD
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