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Home My WebLink AboutMiscellaneous - 96 Kingston StreetDate..... ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that H , c k. r -4-Q i v, ............................................................................................................................ has permission to perform ..... P -A -C-�N4 -A, (e\,-)0m4C ................................. . ..................................... .......... wiringin the building of ............ ................................................................................. at .......! .` ....... L�.. .... . .................. . North Andover, Mass. FeeLic. No2c�2.,. . .................................................................................... ELECTRICAL INSPECTOR .1. Check. 2662r C21mm.onwea& ol��l77�aa4ac1 iu effi . DeparEmed o1. -}ire ` "ice4 BOARD OF FIRE PREVENTION REGULATIONS Of ficial Use Only —� Permit No. W, Occupancy and Fee Checked (Rev.l/07j-^---- (leave blank) APPUCAMN FOR PERMIT TO PERFOIRW ELECTMAL WORK All work to be performed in accordance with the Massachusetts Electrical Code. viEC), 527 C1vrR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORM4 7I0A) D a to : _ 9110 City or 'Town of: No (+\& Andove-C To the In.specror of fflires.- By this application the undersigned gives notice of his or her intention to perform the electrical work described belov,,. Location (Street & I,rmber) '1 ►'� �(�S`��°j(� Owner or• Tenant (lyx,nnr•Ic A rl iress Is this perrnit in conjunction -with a building permit? ' Yes Purpose of Building �� u6L o y __ T'elephone No,%/6•3l�-iseg (P! Y ! pFQ01 No Z (Check Appropriate Box) Utility Authorization No. Existing Service A!-0 Amps Volts Overhead Undgrd ❑ New Service oci Amps ��j�t G Volts Overhead � UndbrdEl Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:Q Q Cmmploli- �flbn („!1„ „1,1 NTo. of Meters No. of Meters i 4W No. of Recessed LuminairesNo. of Cei1.-Susp. (Faddie'J cans _ _ of Tola1 Transformers I\ --VA No, of Luminaire Outlets No. of Hot Tubs Generators kVA No, of Luminaires Swimming Pool Above In- �J ❑ Nv: o merbenc}crno -- b arnd. arnd. Battery Units No. of Receptacle OutletsINo. of Oil Burners �Flf:i', AL—k; 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 t c No. of Waste Disposers. Heat Pump .NR!pber Tons KW ...... _ ((.No, of Self Contained Totals: Detectior,lA ertina Devices t 1 No. of Dishwashers Space/Asea Heating KW ,Local L r`iunicipai L, 0 --her Connection____ —E _ No, of Dr vers Heatin 4. liances - ^� g • PP KW S_"urii- : ysterns:� j`. \o. of F)evices or Enui alent No. of Water -�-- Heaters I�\� No. of No. of Ballasts Signs _ Data «-icing: T - I C 1\o. of Devices or Equivalent - No. Hydromassage Bathtubs No. of Motors Total HP _ 0TI-IER: I ecornlnunications 'hiring~ No. of Devices or Equivalent ;Q 'vp- �d C� . _. 4`C8.1� c` C PG/dJ .S S (i COA Q` V 10 Attuch additional derail if at'desired, a 0.7 required by the Inspector of Wirzs. Estimated Value o • Electrical Work: ..I j��C” (When required by municipal policy,) \Vorl; to Start: P Ir_s aectiors to be requested in accordance with MEC Rule 10, and upon cornpletion, INSURANCE COVERAGE: Unless waived bythe owper, no permit for the performance of electrical work may issue unle_s the iicensee provides proof of liability insurance including "com. -Dieted operation" coverage or its substantial equivalent. Th:, undersigned ceT-biles that such coverage Is in force, and has exhibited D -00f Of sameto the pe11Il!t 1SS1.1mg office, CHECK ONE: INSURANCE F] BOND ❑ OTHER ❑ I certify, under the pails and penalties of perjury, thr_! the information. a,e L`.: ` ?opl:Catfon is true and complete, FrI01 NAME: 11 &oQ o' -edo %-- _ --� LIC. NO.:� Licensee: t C'Nno-.o `c�P `t Signature P. LIC. NO.: A- _ __ —' – A a - (If gnp/icable, Ewer " mpr" it rhe li ense number line.) �{,�n �#��' Bus. Tet. No.: '% Address: _ Q1�� `� -QMt I&S 0`0 G 4 Alt, Tel. No.:_"?- l� ql — 14r(b *Per M.G.L. c. 147, s. 57-61, security wort, requires meat of Public Saft:iy "S" License: L,ic. No. OWNER`S INSURA.NCE WAIVER. I am aware t: ra e Licensee does not he, L bilii, insurance coveraev.: required by law. By my signature below, I i ncby wa", chis requirement. I am t: (c;;__ one) ❑owner ❑ o:; ; :i Tfnt. Owner/Agent Signature Te!ephoneNo. . __— P.ER.hfI7'FEE : S J r t I 09/03/2015 08: 56 Nei 1 & Nei I I nsurance Agency (FAX)14137316629 P . 001/001 i �.`CbjT�'� CERTIFICATE OF LIABILITY INSURANCE DA 0!03/2015 THIS THIS CERTIFICATE 1$ ISSUED AS A MATTER'OF INFORMATION ONLY AND CONFERS NO RICHT$ UPON THk CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,, EXTEND OR ALTER THE COVERAGE AFFCRDFD BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTA1VE OR PRODUCER, AND THE CERTIFICATE HOLDER: IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed, if SUBROGATION IS WAIVED, subject to the terms and conditions of ths'pollcy, certain policies may require an endorsement. A statement on this oertlf cats does not confer rights to the certificate holder In lieu of such endorsement(s), PRODUCER Neill & Neill Insurance Agency Inc 882 Riverdale Street West Springfield, MA 01088 David Jarry PHONE (413) 732.4137 a ,1. 1: (413) 731-6629 ADoae t INBURIINf9l APFORDINO COVIERAOE NAICN INSURER AI State Auto: Insurance Company STA INSURED Michael Farelll Electrical 8 Applewaod Lane Methuen, MA01844 INSURER a: Acadia Insurance CD, I 31325 INSURER C: NSU E D• IN6 RFA e INSURER P. T20VFRAnF9 ❑FRTIFICATF NIIMRFR, RFVII4IPIN NIIMRIPP. THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ASOVE 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 FOLICIES, LIMITS SHOWN MAY HAVE BE> N REDUCED BY PAID CLAIMS. ,NSR TYF'E OF INSURANCE TH. EXAIRATION DATE THEREOF; .NOTICE WILL BE DELIVERED IN iSOO Osgood Street, Building 20 POLICY NUMBER M D M !DO LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIM6-MAOI; 7pCCVR I SOP2745517 08/1012015 0811012016 EACMOCCURRENtE $ 1,000,000 r n s SD,oaD MEDEXP An one rson 6 51000 PERSONAL& ADV INJURY 3 1,000,000 OENERALAOOREOATE b 210001000 GEWLAGGRFGATELIMIT APPLIES PER:' POLICY 71P - LOC PRODUCTS-COMP/OP AGO 6 2,000,000 6 AUTOMOBILE LIABIUYY ANY AUTO ALL AUTSULfiDUTO HIRED AUTOS AUTOSEO SODILYINJURY(Per pereon) 6 BODILY INJURY (Pereoddenl) 6 pR0 ERTY MAGE 6 S UMBRELLA LIAR EXCESS WAN HCLAIMrpMAD.5 OCCUR EACH OCCURRENCE i AOOk9OATE 6 DED RETENTION 6 S WORXERSCOMPENSATION AND EMPLOYERS' LIARILITY ANYPROPRIETORiPARTNER=ECUTIVE OFFIC1 11MEMEER EXCLUDlD7 (MmdstoryIn NH) If Yee desume under DESCRIPTION OF OPER AT10N6 below NIA WC -20.20.001461.06 03/20120iS 0 01 - OT . E.L. EACH ACCIDENT 6 - 100,000 _ E.L. DISEASE. PA EMPLOYP6 S 100,000 E.L. DISEASE. POLICY LIMIT S 500,000 f DESCRIPTION OP OPERATIONS I LOCATIONS IVEHICLES (Atteah ACORD 101, AddlUond Remota SchWub, If mon epees Is mQuired) Faxed to: 978.882-1460 6 v i CFRTIF,r'ATF W1111 IMPR CANCEL, OTInK1 ! G11ROO-Y414 AGt7RIT0OIippRATKWAll rignts reserves. ACORD 26 (2010106) The ACORD name and logo are regis Bred marks ofACORD 1 i : I � SHOULD ANY OF THE ABOVE DESORIPED POLICIttS BE CANCIELLeD BrPOl Town of North Andover TH. EXAIRATION DATE THEREOF; .NOTICE WILL BE DELIVERED IN iSOO Osgood Street, Building 20 AC�OhDANCE 7H THE POLICY PROVISIONS. Suite 2035 North Andover, MA 01845 AUTHORIZED REP fi Ar1Vk i I G11ROO-Y414 AGt7RIT0OIippRATKWAll rignts reserves. ACORD 26 (2010106) The ACORD name and logo are regis Bred marks ofACORD 1 i : I � The Commonwealth of Massachusetts Department of IndustrialAceldents X Congress Street, Suite .T 00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Orgarization/Individual): Address: A L! �_uo ;r.yx Lan t, Cit /Stale/Zi 1�1. Sr C-) < < Are y au employer? Check the appropriate box: 1. a Iain a employer with _ mployees (full and/or part-time).* 2. I am a sole proprietor or partnership 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.] 4. ❑ I am a homeowner and will be luring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance. 6.F] 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): 7. ❑ New construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.[dFlectiical repairs or additions 12.0 Plumbing repairs or additions 13. [] Roof repairs 14.❑ Other _ *Any applicant that checks box #1 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. mustattached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their_ workers' comp. policy number. 1" am an employer tliat is providing worker -s' compensation insurance, for' my employees. Below is the policy and job site information. p Insurance Company Name: L �� 4 9V e ` I ( IjWu ( o ACG_ � — Policy # or Self -ins. Lic. #:_ LU U ` (>" O 1 i a '' Expiration Date:_S_Lj'l:7 Job Site A.ddress:� rte S" 'tf) r �� — �' vl City/State/Zip: o4L A0 C) �� y Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA. for insurance coverage verification. I do hereby certifyunder thepains andpenalties ofper jury that the information provided above is true and correct. g�Q i_! 1 Phone #: 9! A- 9a 3 a t — 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 #: