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HomeMy WebLinkAboutMiscellaneous - 80 BRIDGES LANE 4/30/2018 (2)Date !.�- 411 ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.......1......................... tCi-- J rr-� ..� c..:....J.......... ��...`... � . °.(�(...'..... . has permission to perform , �'� 1 . V U, 5c,�V ................ .. w. wiring i�n the building of....L01A1�....................�........................................................... at ...... t1..t✓....... � 5 "!" ................................ �Iorth Andover, Mass. Fee. ....��............ Lic. No. A I.... ........�...............^�?.� >.. I 'LECTRICALNSPECTOR r/ Check # U -,-1 1 2c7 DOARD.OF FIRE PREVENTION REGOLATIONS Pont row_ Offi'aiiall UpeO�nly Permh w Ompawy "d ree chedad Rev.lf" a APPLiCATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be Wrormod En acmdance with the MNSOC11U8 . Jale 1fieg {:ode (MEEL 527 C—MIR 12.00 (-P, - t'Pi? h R 7TPEAIJ INFORA" TION) +tviRy 'L'cnwrr oi: North Andover _ To ME.InspEctor of Wiremr: By Chis applicxWn the mndersigned givesmifee. of his or her iMmijon to perfwm the eloo Tical vAA described below. 1.ocafiiim (Strer4 & Nmmbejt) 80 Bridges Ln Ower arTo■rat Patrick Louis OwmWs Address Telepaione r (978) 686-2935 Is this p0 mit in Wnjanotlim Witbi a (Funding mit?' Yaa ❑ NO R, (C:betk Appropristo glow) purpo" of Building Utility AutFF Owlian Not, I New Seryk aAmp® f volts Overbad ❑ U mdgrd _ IVunn'bmr of <7eadVara and' Amp adty c l,+veufim Aalpi N;Fturr' ofl"�n�ia�t �liaeriW urk: ins�'llnElorl oiT;a, RaatvGnpe, Nr1�l1�# E�r�i�rt° �'l�� $j�1l�l�rlk No. 01r r5ft— I Recessrall No. at Larm.i>n■Yrrs No ref 0¢11.-3uapb (Paddle) Farm °%rt8(aF" tem _ X'A Nob ai.l,+uMintne tllnadPeY.s iy'+a Of IIIQt 'ivbs t�caa:roTtrr� ii4'YA -iYnL oi:t�um �wlmnving ihaa�l d• � , PAd. IJ Behr , Units NU• of Yitoeadp#■¢lr t>'■tlara ' N&*11`01 biurnora �I�7F#g ALARMS Nir,. orZonsa N(h @f BgtF oOf � F I InYlleRln 1]MTotal Acea. No, a(YRe■ces No. ot'Alr Ca■d. lion Q. od'.AIEoPtiing D.Mcm LVab of Waste tJispesm mp, 13M-� .;_� Q. :; ant■ _ _ 1Y'o1��a �--- I�fie�lioFdAtldFlu>A li�vioas No. of Wlfewash 8pwaxi,Are■ Ikwting KW �1a1 � `unFc , •' � piY>cu` C'annsab No. of YDrym YYim1Yng AppilYa�e+sa K1V<+ p tY No. of or F' 4iv■ic.:# No. .'star KW 'a OF o. o Data Wiring; Healers $i -us Yletimses N,y,+afDcviiGoso .�1dar.�i m�tirSarnaf u�va�l .tf'�sA r� � m vxr�u�€,nd' hy' i� 1nr��e4nr of ll►'bar. frs9ilnsted VNIpe Gf El�wtriL-al 'Vk'o€i::.$.1199 %em required by avunio pa[iey_y Work to Stent: InaRGctiums to UG Ngpestad 'rn actaol'dencG %*4 MEC Rule E4..end upon GampliolnanL INSURANCE CC?'4'1+.1AGE: Unless waived by the owrrror, no permit foT tfie perfuxrrmns'ac a!'cloctrimal warlc may issue unless the Eiccnarvc RroeadGsi prnaEafainbality irraue including `Naoorlp9dodl operation" agG of its SubGtnrAinl equ1YolGm. The 1mWnxsignt•d crartiEues tlr■t sun:Er oonr4c is in iiaroot mW has. oxhiixitGd pmi°oEsarne c permit Csm►ring offikt. CHECK O M41RA1'30E ID BOND OTHER [j LSpeeif�:) coenrP, Mndff pgiio mwd',pWGi9t#'eJ Sat dura a'n, jarMavloff 4M its trNf aM jj�e 4fpd*.7� FIRM fYA7N:E: VivinE, I`.nc UC. Ma: 1471 G il.<iod S#art B. tpr.da $;,Oatrtrre LIC Nat 1471 G q/+qvn'kwW. "Wavtx'!p A4rli,Wnsa.evUubarME) B■®, TA C'+lax� tQ.7Ti4•+BI=1!l ,+kddrom- 4031 Noah 900 West ftam UT 13dG04 - rldit. TeL l5la.; (W) 479-101' *Fcr NI.O�E.,. m. 147, o• 57�+6I r WCuritX Wbrk,'rqain:s Q3cpartrucnt of Public "S" Laasrtst:. [jcPAu. 89C:OaC Ql!'Nf Nittfi°S I:NSU:fACVC:E WA1VEW l 4M� a++r®ac tlitd: iEra' UGtni ra'nras nrrt rhe imrame haw cor+rsrng[: norrtrbliy require(E by lew• By my t3,roture iia t hfy waive lt±ifi myii#iernM. Y am the {cheell< one) owneR 0 eFVFrrer'a t. 0w■odAgerrt Signature Telephone r uinr■Ilant No, 1#'gdx�wnoie�.Bartlylptr�s Na+opMalnMr�s Totillii.P�jt^si nonan 4oa ■ No, �y ;',lease visit our web site at http://www.mass.gov/dpl/boards/EL VIVINT INC STEPHEN B COPPOLA (FA) 17 STONE BRIDGE RD GROVELAND' MA 01834-1751 Fold, Then Detach Along All Perforations .0 <:GC�`MMON:W LTH Of= N#53HltS�T .,.<.< r •9 Iwo11, a -s • Lf GTFt I C l ANS ,1 ISSUES THE FQLLOWI N=L.1Ei�SE� AS p;�Gb I.�RED SYSTEM CpNTRACT012 V=19T INC ., ST'EPHEN,, B CORPpLA I '1:T STONE 1�R1=DGE G,ROVELANp d 0183-1 1751 X7972.8. Commonwealth of Massachusetts Department of Public Safety �r-curiiti. iii^nn- ti. Lirruo •�—' License: SSCO-001351 STEPHEN B COPPOLA 4931 N 300 W Provo UT 84604 r 1 Expiration; Commissioner 07/22/2015 ACOROCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS 11111/2014 -THIS CERTIFICATE IS 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 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). PRODUCER MARSH USA INC. CONTACT NAME: 122517TH STREET, SUITE 1300 DENVER, CO 80202-5534 Attn: Denver.CertRequest@marsh.com Fax: 212-948-4381 PHONE FAX A/C No Ex • AIC No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # EACH OCCURRENCE $ 1,000,000 INSURER A : Lexington Insurance Company 19437 INSURED Uvint, Inc. INSURER B: Zurich American Insurance Company 16535 INSURER C : American Zurich Insurance Company 40142 4931 North 300 W Provo, UT 84604 INSURER D : INSURER E: INSURER F: nwIIJIWN "UnnoCR: i 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE vvVnPOLICY NUMBER MM/DD/YYYY (MMIDDIYYYYI LIMITS A GENERAL LIABILITY 014180795 11/01/2014 11/01/2015 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ CLAIMS -MADE Ifl OCCUR MED EXP (Any one person) $ X EA WRNGFL ACTOR OFFENSE PERSONAL & ADV INJURY $ 1,000,000 X SIR: $25,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000 X POLICY PRO- LOC $ B AUTOMOBILE LIABILITY BAP509601200 11/01/2014 11/01/2015 COMaccident BINED SINGLE LIMIT Ea 1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ IX AUTOS AUTOS HIREDAUTOS X NON -OWNED AUTOSPer PROPERTY DAMAGE $ accident $ - UMBRELLA LIAB OCCUR H EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ C WORKERS COMPENSATION WC509601000 (AOS) 11/01/2014 11/01/2015 XWC STATU- OTH- B AND EMPLOYERS' LIABILITY Y/N E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N N / A WC509601 100 (MA) 11/01/2014 11/01/2015 (Mandatory in NH) If yes, describe under SEE ATTACHED E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance 3 Town of North Andover 1600 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M. Parsloe v Tarts-ZUIU AGORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD j ACO 16.,.E AGENCY CUSTOMER ID: 044605 LOC #: Denver ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY MARSH USA INC. NAMED INSURED Vivint, Inc. 4931 North 300 W Provo, UT 64604 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WC Policy WC509601000 includes coverage for the following states: AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, MI, MN, MO, MS, MT, NE, NJ, NC, NO, NH, NM, NY, OK, OR, PA, RI, SC, SO, TN, TX, UT, VA, VT, WV, WY AWKL1 1U1 (ZUUt51U1) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Date ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies tJ�.,\J.I:j.... ..... . 1pw 'A has permission to perform :,i -i............. ; ........... wiring in the building of,.,,. ... V'5 ........... �14�j �1� ............... ...... .............. ...... .... : ................... ae ..................................... .................. t'j..� ................. ?-North Andover, Mass. Fee.45� ........ Lic. No . ................. .......................... . ELETRICALINSPECTOR ( Check# rZx eqWffiW4.fftA 01 SOARD OF FIRE PREVENTION REGULATIONS Pff M Forth 10T, * I Use -only Perivik NQ_ Oce pancy and Fec Cbedktd !Rtw, I M71 (;pvc l�jkqnk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wu& 44 be pedbecitPA in aixafdanoc with the Mfi3Wj_1U&e0s 1:1celf;t3i CO& CMECI 527 CMR 12-00 r P1 F.4 SR P RW 1jV INK 0 R TYPE A /J. JYFO RMA 7109) Date. I City -Dr,'Town of, North Andover To the 1",T)mcier of Rywx: By ffiszpplicaw-a the ttndcrsi�gncd sgiaysnclicc of his or her hn1cffbonto perform theclectrical vAA dcscnkdbclo-A,. Locative (Strect & Number)_ 80 Bridges Ln c)wcer or rerimnt —Patrick Louis Telephone N* (978) 686-2� Owuer`s Addma 80 Bridges Ln Is thiN pumit in ocmijanotiovi with, st building; pcmit? YCS [:] . [j]r (Choth Appmpriiitc lit.) Purposm of 111vildimg Utility Aullikvii7ation No,, Exl9drig Service _ Amps 1 volts Gvedbead ❑ UndVrd 0 1jg&,j&CdM _ Amps I Volts Ovedmd undgrdD Number of FM*rs and Ampidtly Nob d Meters NN of meter's 1,6catiom AM NiulurV of Pr -"ed KlectricAll Worliz installation oll a low -voltage, mless bur&r alarm, symcm� EfifficLwim mrdin &HnW1ncF f0hiff ~11 A. —1—d kw iP ar hh—e.. ­rs. Noi of R Lumilmirea N66 cif Cvg,-Smp6 (Padill16) FansTotal TraiisfornteiT__ XVA No, of LuinioulTv 001110ts Na, lot Hot Tox ("emeratma K -VA Nc of Luminaim AIWVe cl Ift. SWIMMIRS Peat Rrad.. rod, Battery Units INiu,''Of Re"P411c1e outicts rfo-orod 80m.ces FIRE ALARM or Zwnn NW.—Or 10111jow"an aTo datirst No, of Ranges Total No 06 c(Air CoocL Tm No. of Atertft Devices N.c. of Waste Dfspe osm Tow M QM 10 -pillf-Contzmed: JT No, a(Diomrisers Spwc*lArva 11jealiRg KW Ej Munkit.ppi fytfier conne an D Nc� of Drycm Illeating Apoliances KW secar-ritys tem!l.- N lot CZ, 1 6. cs or Vagivviomt No. of'WaterNo. liftlers K:W of .I; , # Ar ft g I Wlaku Data wwmg; Nix of Dcvk.cr, or EauNallerd No. Hydromassage Bothlubg140, _E; ormolo" Tool HP 1. Wiring, Niaof Device c or Ll ER: Ar1Wj auWfAaffaf dawfl.Y danVeg or zff mquk-ed fly dw ImpefWr of wove: Mma4ed Value of Electrical Wo&--- S t99 (When required by inu6cipall policy_) Work to Start: InspIxtions to be requested in accordance with MEC Rule 10, and upon compiction- INSURANCE COVERAGE: Unicss wm[vW by the owner. w pcTm[i 66T the perfonnanoc of clectrical woric may issue arLicss t,he bocrisce provides proof Dfliabillity insumpoc inchiding "comp qPciration" 01pvcIrk" oT its 3ubscamid cquivallcrvi. The to Me permit iSMdr%-Uifr0c, CHECK ONE: MURANCE (L BOND[] OTHER E] (Spedify,.) I tvNify, mider nke.palas s"dpemMes qfptvjkq, (6v the 0irfarmadim vn t fimko,&" Is tm e and calwele. FIR311 NAME: ViAnt. Inc wC, N(j, 1471 C llicefflatee- Stephen B, cwPola Si gRilr t, 11re_LIC, NO.: 1471 C f1fam?Va6k. cater -r.empf- M the ffcmw number fhrj Bus. TA No- (aT7) 4MIG67 Adftcss, 4931 Norlh 300 West!RovcUT 84-604 AIL TeL No,: (877) 47-5-1 WT *Per M.G.L. c. 147, s, 574 1, smifinty vxwk rcqvirrs DcpirtTnrnt *F public So* "S" 1.kcrisc uc. NO- ssco-001361' OWNWR'S 1 NNU RANCE, WAN VFM I am awme Oft the LiCemwe dmT nal hare Oe liability insuratwe coverage normally ,required Ixy haw. By riTy slynowre below, 11 heft -by waive ihis Tequirernend. I affil 16101acd one [_1 owner 1:1 owner's ftftt, OweerY.Agent sigmi'dre TeleNshone No. PERMff FEE't $ 45.00 _F IkV+w vacl-ts ?I 'A- eD E x e N c�' r `� Please visit our web site at http://www.mass.gov/dpl/boards/EL VIVINT INC STEPHEN B COPPOLA (FA) 17 STONE BRIDGE RD GROVELAND MA 01834-1751 V Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS V 1 Commonwealth of Massachusetts Department of Public Safety License: SSCO-001351 ` 1 STEPHEN B COPPOLA ,��. r, ~ 4931 N 300 W Provo UT 8146044 Commissioner Expiration: /2 r 2015 O7I22/2015 A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) „/,,,20,4 THIS CERTIFICATE IS 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 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). PRODUCER MARSH USA INC. 122517TH STREET, SUITE 1300 DENVER, CO 80202-5534 Attn: Denver.CedRequest@marsh.com Fax: 212-948-4381 CONTACT NAME: E FAX PNC NNo Ext): AIC No): ADDRESS: GENERAL LIABILITY INSURERS AFFORDING COVERAGE NAIC # INSURER A : Lexington Insurance Company 19437 11/01/2014 INSURED 4931 4931, Inc. North 300 W INSURERS: Zurich American Insurance Company 16535 INSURER C : P Y American Zuricnsuranceoman h IC40142 Provo, UT 84604 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: SEA -002505016-01 REVISION NIUMRFR- 1 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. INSR LTR TYPE OF INSURANCEMM ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD LIMITS A GENERAL LIABILITY 014180795 11/01/2014 11/01/2015 EACH OCCURRENCE $ 1,000,000 MERCIAL GENERAL LIABILITY �17CLAIMS-MADE DAMAGE TORENTED 100,000 PREMISES Eaoccurrence $ M OCCUR MED EXP (Any one person) $ X -EA WRNGFL ACT OR OFFENSE PERSONAL 8 ADV INJURY $ 1,000,000 X SIR: $25,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X POLICY F7 PRO- LOC iEcT $ B AUTOMOBILE LIABILITY BAP509601200 11/01/2014 11/01/2015 COMBINED SINGLE LIMIT 11000,000 Ea accident X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS (Per accident ( ) BODILY INJURY P $ X NON -OWNED HIREDAUTOS X PerOPERTnDAMAGE $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ C WORKERS COMPENSATION WC509601000 (AOS) 11/01/2014 11/01/2015X WC STATU- OTH- B AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N WC509601100 (MA) 11/01/2014 1110112015 LMT:S FR 1,000,000 LN] N / A E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) SEE ATTACHED E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance Town of North Andover 1600 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M. Parsloe tL�.!li.�x ht. fiacd/rG ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Date ..... $..�•�! TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....................( tt.i........... ........................................ F has permission to perform ........,�4/r. ...t.ce........ ®!.4--..!f4 &&oz......... wiring -in the building of................L..Q.v[...................................................................... atZ7....�1P�(� f --C. . ..... ............................� .. > North Andover, Mass. Fee..-? ..�' ...... Lic. No. ���. .. ......,�. �.. ........................... ................: �.................... 'r LECTRICAL INSPECTOR l� Check # "T _ i j �j� { q "7 D �C\ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. C) Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank 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 WK OR TYPE ALL INFORMATION) Date: 'fig C . I S — int 4 City or Town of. NORTH ANDOVER To the Inspector of Wires.- By ires:By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) gp $stn€g Owner or Tenant I .�V�.=� Telephone No. (?7 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 ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work:Ew EMRm lA►c.a� 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- E] rnd. rnd. No. o Emergency Lighting Battery 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW ""...........Detection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Connection E] Other 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 CfiHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: 12 —1 a — I 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. LIC. NO.: Licensee: —ISMy l ytqM F Signature „N,,.� 2AJA;n,,,,,,Q, LIC. N0.: 31 Cp9 5 - F— (If applicable, enter "exempt" in the license number line) V Bus. Tel. No.. 97A !?9 �{ Address: Alt, Tel. No.: G=1 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: 1-ic:,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 PERMIT FEE: $ Signature Telephone No. 4 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed _t on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by'establishing an aiitomatic.four=year, extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: '***'Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Sigriattare: Date:, , SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: r Inspectors Signature: Date: 4 PARTIAL ROUGH INSPECTION: Pass F71 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Datg: ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Commen' . Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual): —rZM yn1NE ► •' City/State/Zip: N1_w,2nN NtJ X58 Phone #: gLlb clgff %221 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. F1 Now construction ' employees (full and/or part-time).* have hired the sub -contractors 7. E]Remodeling am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9_ 5. ❑ We are a corporation and its ❑Building addition [No workers' comp. insurance 10.E1 Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' 13. ❑ Other 41 comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tds ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic. #:. Expiration Date: Job Site Address:&PVMbG2tS LA14E NO(231f i414MJEP_ City/State/Zip:MA 01845_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 ofperjury that the information provided above is true and correct. Phone #: !j'TS q9'-[' !0221 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 r Informati®n and Instructi®ns 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 ofhire, 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(6y, 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 number(s) 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 carry 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, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' Y 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 burn leaves etc.) said person is NOT required to complete this affidavit. i' 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: Tho Commonwealth of Massachusetts Department ofIndustdal Accidents Office of favestigation.s 604 Washington Stfeet Boston,. MA 0.2111 Tel, # 617-727-4900 eyt 406 or 1-877�,MASSA.FB Revised 5-26-05 Fax ## 617-727-7749 wwwanass.govldia