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Home My WebLink AboutElectrical Permit #12456 - Permits #12456 - 131 COTUIT STREET 6/16/2014 I, f ate«�,...,.. ,...dww«ti..u....«.....,,....�..�.�.. T TOWN OF NORTH ANDOVER PERMIT FOR WI,RING J� HU Thi a f I' . rig � .......:.....:...«...w........«..,..... � o. , e�. a has i i on tol fof' , .�wMww...«......,....._....... .,�............ ...........m......w.w*.,..w.�www wa-ing in the building r..........,b«w,.w ww.Mw.wwaws,.........wwwW.w.wp..« ..www,w w.ww,«.w«««w,.....� a .w w,««�ww.gww«ww«mow........,,......�«...,....w«.....«............. w.ww,w w..ww..w,w«,f„........x„«..w,«,..«. Andover,. I Lic Fey m..,.w, ....,.w�a w,� 4"�„mi'.w LE Check t A Off,16'al Uso 0111Y Uommoawea 0I aij,jaC4,"Jottj Pemi't,No. 013ire i"icei Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] have ble APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK A11urork to be ptr1fonned lin accordatice With the Massachmotts Electrical Cod Q,527 CMR 12.00 (PLEASE PRINT ININK OR T ALL INFORMA TION ity ctor C or Town of: TO the Inspe of"Wit-es.- 7' &Y�m �/- By this application the undersigned gives nte of his or herfiltention to perforin the electrical work described below. Location(Street&Numbeii-) IS1 Owneroi-Tenant Telephone No,6 U Owiner's Addr-ess ( A ,i Box) Is this perinit In conjunction with a building perinit? Yes No Check ppr op -late Purpose of BuIlding Utllity. Authorization No. LL Undgrd El No.of Metei-sYu Existing Sevvice Am,ps Ott$ Overhmead No of Mes New Sei-vice Atups ""dolts Overhead 0 UitdgrdE] . ter Number of Feeders and Ampacity Location and,Nature of Proposed Electrical Wolr,k: vlleA ct YO, IN 'I theLollo2:�j tab )erabe ivawed'Aythe hits ecitp?-pf Wires. No.of - lNo.of Recessed Lumina o.oie .- tip. P ans Tvansfortners KVA lNo.of Luminalre,Outlets No.of Hot Tubs G.enerators KVA Above Ei Iu- No.of Emergency Lighting No.of Luminaires swiminhig Pool Smilib gruld. Battelli 11,ts, No,of Receptacle Outlets No.of Oil Builmers, FIRE,ALARMS iNo*of Zones W .... ......................I f Detection and No.of Switches No.of Gas Burners Initiating Delvices Total r Cond. of Alerting Devices No.of Ranges No.of Al Tons art Pump Nuniber XW No.of Self-ContAined No.of Waste Disposers ............ Totals. Detection/Alerting Devices No,.of Dishwashers Space/Area Heating K I W Local I Cio nicipa El Other nip secul-ity S Styso No.of Di-yers Heating Appliances KW Levices'.or Equivalent o.of rter KW No--.Of of Data Wiringio , Heaters si s Ballasts No.of Devices ot-Enittivinlent Telecotimunications,Wirl 10 'No EquivaTent No i-.1-1ydoni assage Bathtubs I�N t o,.of Moors. Total HP of'Devices or OTHERt Attach addirimal detail ifdesire4,or as)-eqtiared b.y die bispector of Wives. Estinlated'Value of Electrical Wofk,:, Mien required by municipal policy.) Work t,o Start: Ins tons to be requested inaccordance with MSC Rule 10,and upon completion. ,P I W1 INSURANCE COVERAGE,., Unless waived by the owner,,no perm it for the perfminance of electrical work may issue unless the licensee provides proof of liability insurance Bilicludn"19"completed operation"coverage or its substantial equivalent. The undersigned cellifies that such coverage iis in force,and has e,xhibited proof of same to the,perni'it issitung office., CHECK ONE: INSURANCE 0 BOND [:] OTHER [:1 (Specify-.) I'crrto.,m;der the pains findpen allie,is qfper)miir,FU vithe h(formallon on this i7pplictillon Is brieie o7nd complele.M NAAIE LIC,N . 00 4111MLL6 Signature LIB".NO.- (If 16 iapplicable,enter"exellp'01 t iii the liciensle munber live) Bus.Tel.No*, Address., Alt.Tel.N . *Pier M.G.L.c.147�si.5761,security work requires Departnient of Public.Safeity"S",License: Lic.No,. OWNE RIS INSURANCE WAIVER: I ain aware that the Licensee does not haile the liability'insurance co erage normally r k d by law. By my signature below,I hereby waive thi ment. I am the(check one ovaier El owner's agent. equffe I is require Owner/Agent 4 PERMIT signatul,e Telephione,No. The Commonwealth ofMassachusetts Print Form P -tiro Department ofhidustri alA cchltv itim Of i is ce of hivest g( I Congress Street,Suite 100 -20,17 Boston,MA 02114 wivivmass,govIttia Workers' Compensation Insurance Affidavit: Bu ilders/C nt to rs/Electr ic ians/P lumbers App licant Informat Please Print L�gibly ion 'Name (Btisi�nes,s,/Organizatioii/individtial.): Astrum,Solar Address4 15 Avenue E, City/State/Zip: HopIkint,on, Mal 01 Pho 748 #-508-208-618,4 ne Are you an employer?Check the appropriate hox,-,,, Type of project(required)- a a ge I.ED I ani a,employer with 15 4. E] Im neral contractor and I 6. New construction have hired the sub-contractors em loyees(full and/or part-time).* P listed on the attached sheet. 7. Remodeling 2,El I am,a sole proprietor or partner- These sub-contractors have 8, F1 Demolition ship and have no employees I working for me in any capacity. ernployees,and have workers- 9. E]Building addition [No worker�s' comp.insurance comp. insurance.1 1 5. 0 We are a corporation and its 10.0 Electrical repairs.or additions required.] off, i 3.El 1,am a hoi"neowner doingall.work i icer�s have exercised their I LE] Plumbing,repairs or additions myself [No workers' comp. right of exemption per MGL 12.E] Roof repairs. insurance required] c. 152, §1(4),and we,have no 13,[Z1 OtherPV'Solar Installation employees. [No workers" comp.insurance required] *Any applicant th'at checks box#1 nuist also fill out 1he section below showitig their workers'conipensation policy infor.niation. It Hotneowners who submit this affidavit indicatitig they,are doing all work.and then hire outside contractors MU St SUbmit a new affidavit indicating such. :Cotitractors ffiat cheek this box 111USt attached an additional sheet sliowing the name of tile sub-contractors and state whether or not t hose entities have employees. If the sub-co have eniployees,they niust provide their workers'comp.policy number. I'ain(tit eniphqer that 1'.5 provitfing tag orkers'cotitpensaflon i"nsitralleefir mj�emp,loyees., Fa it i's the,policy andjob site M hi.forntation. Insurance Company Name:Zurtch American Insurance Co. 4640926 Ex pira tion Date.1,11/2014 Policy#or Self-ins.Lic. I ezt h Well,City/S,tat Job,Site Address: Attachit copy of the workers'compensation pollicy declaration page(showing the policy number an equ d.u d expiration date). Failure to secure coverage as rirender Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year im.Prisonment,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 lie fiorwarded to the Office of hivestigationos of the DIA,for insurance coverage verification. I t10 heu-eb ertify iiiiVer the pains andpenalties qtLeijuly that the inlorma Corr, rovUed above is ft-tte and correct. Date. ature* Phone Official its e oiilj�., Do not tPi1te I'll thl's area,to be coinlVeled bj7 city or toivn Qf haps. lic* I Date=. , E7 1 City or Towii: Perm 1"t/License# Issuing Authority(Circle one). 1.Board ofHealth 2.Building Department 3. City/Tower Clerk 4.Electi ical Inspector 5.Plumbing Inspector 6.O thee- contact Person-. Phone A. TRU-1 OP ID.SJ p � DATE(NIMIDDfYYYY) CERTIFICATE OF LIABILITY INSURANCE 0110712014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEN. THIS f CERTIFICATE DOES NOT AFFIRMATIVELY TIVELY 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), AUTHORIZE[ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE FOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollc (ie )trust be endorsed. If SUBROGATION IS WAIVED,subject to } f 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). r PIODl1CFlf CONTACT r NAME: u Diversified Insurance PHONE FAX Industries,Inc. A.rc Na Ex!): A#c Ho: Suite 155 West,2 Hamill Road E• AIL Baltimore,MD 1210-1873 ADDRESS- Steven I'.Johnston INSURER(S)AFFORDING COVERAGE NAIL# Ww INSURER A:Ohio Casualty 14613 INSURED Astrum olatr,Inc. INSURER E3:Cincinnati InsuranceCo. �10677 5 hlenl el bane Ste 508 INSURER Chesapeake Employers InsCo � '1'1 Annapolis Junction,MD 20701 INSURER D: urlch/Ameri an Ins.Co. INSURER E: r,N.U,R.R.; 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 THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS. IN R ADDL.SLISRPOLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE � POLICY NUMBER f4fMIDDIYYVY YYYY MMIDDI GENERAL LIABILITY EACH OCCURRENCE '11000,000 MA.A COMMERCIAL GENERAL LIABILITY Bt'S55683 48 08101120'1 081011 014 PREM SAS 4�occurrence 3009000 CLAIMS-MADE I x- I QOCUR MED EXP(Any one person) 10,000 PERSONAL&ADV INJURY 1,000,000 GENERAL AGGREGATE $ 2tOOO9OOO GEN'L AGGREGATE MIT APPLIES PER: PRODUCTS-COMP/OP AGG :0081880 P OLICY P -T oc AUTOMOBILE LIABILITY COMBINED accident)SINGLE LIMIT 1,000,000 B X ANY AUTO EBA0054872 12/20/201 12/201 0'14 BODILY INJURY(Per person) $ W ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ m AUTOS AUTOS IKON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Pt�R�ICCIDENT} w $ N $ UMBRELLA LIAB }( OCCUR EACH OCCURRENCE 103000,000 EXCESS LFAE3 Ct AIi1+1 - AFr4 U05554�42 6810�1 J0 3 08#01120'I4 AGGREGATE 0,0000000 DED X RETENTION$ 105000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS`LIABILITY if!I ITORY.M—ITS ER ANY PROP RIETORMARTNERIE ECLITI E 4640926 01/011 014 0/10112015 E.L.EACH ACCIDENT $ mot000 OFFICEWMEMBErR EXCLUDED? R NIA �0080 (Mandatory HF E.L. - AD 1 EMPLO If es,describe under 80 888 [DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ s Commercial Package BKS55683248 08/01/ 01 0810112014 BusPrsPlrp on file A Inland Marine II 8950782 08101/ 013 0810112014 OolntrEquip on file DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if snare space Is required) CERTIFICATE HOLDER CANCELLATION I F R01 r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EFORE r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover,MA "i 4�J AUTHORIZED REPRESENTATIVE ------------------- 1988- 010 ACORD CORPORATION. All rights reserved. ACORD 25( 01010 ) The ACORD name and logo are registered marks of ACORD