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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