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HomeMy WebLinkAboutWiring permits - Correspondence - 1160 GREAT POND ROAD 11/9/2012 3 f= Date . . •�r��tct�a ryws-: w TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . � ' ` :� . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . wiring in the building of . . . . . .1 ®� } � �� at � �'� ��� . ' North Andover, Mass. f .Fee .�-7`.�,.7:,Lic. No. . � 4� . . . . fl ELECTRICAL INSPECTOR �I Check# I `a 1 Official Use Only Conunonweahk ol MaJJi9c1­JeYJ F i 2 ( 2— 77 Permit No. occupancy and Fee Checked BOARD OF FIRE ID REVENTION REGULATIONS [Rev. t/07] (leave blank) APPLICAMN FOR PERrYfflT TO PERFORNN ELECTRMAL ��,/Affln),K All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12, (PLEASE PRIN7'IN INK OR 7'YPE ALL 111101 Al1y,17'10N) Date:--- c D City or Town of: v-W r To the Inspector FT17re By this application the Undersigned gives notice of his or her intention to perform th electrical work described below. Location(Street& Number)— c' Jb Owner-or Tenant Telephone No. 0 Owner's Address VE� Is this pernift in conjunction with a building perinit? Yes ❑ No F-1 (Check Appropriate Box) Purpose of Building — Utility Authorization No. Existing Set-vice Anips Overhead ❑ Undgrd ❑ No. of Meters New Service Amps Volts overIv-adFl- unal-'rrd El No, of Meters Number of Feeders and AfflPficitlY �❑�f y� __�� __., �u�_... ,��.._ Location and Nature of Proposed Electric pi sKi al Work: D I Coiiipletioiiof the.folloit,iil,, able inaybe iiwii,edbythe Lis pectoro No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Faris Transfo rEn ci's JKVA No. of Lurninaire Outlets No.of Hot'rubs Generators KVA APoove Ei [n- I .6 niergency Fg ifing ninl No. of Luminaires Swiing Pool gi 11d. ❑ grad. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Detection and No. of Switches No.of Gas Burners Initiating Devices Total No. of Ranges No.of Air Cond. Tons No.of Alerting Devices -1111eat�Pump Num ��N�y bet Tons N ined No. of Waste Disposers Totals: .......... ... Detection/Alerting Devices­­­ �-,—Municijpa I F1 Other No. of Dishwashers Space/Area Heating KW Local El conRiection fleating Appliances KW security Systeals:". No. of Dryers No.of Devices or E(juivalent No. Of—Water W No.of No.of Data Wiring: fleaters Si-Ils Ballasts No.of Devices (jK Ejuivatent Wiring: of kliotors '(Pot i9P Tv. No, Ilydroniassage RaffitUN, I o' UeviezS oz o,rIIER: A 0 Attach additional cletail if desiree-1, or as reqWred by the InsImetor of Wires. Estimated Value Of E e trical Work: , (When required by municipal policy.) , Work to Stail: 0 Inspections to be requested in accordance with N4EC Rule 10,and upon completion. INSURANCE CO ERAGE: 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 coves-5�,is in force,and has exhibited proof of same to the Permit issuing Office, CHECK ONE: INSURANCE [VBONDE] OTHERE] (Specify:) Icertify, under the pains and penalties 0y' 411u, that the information on this application is true and complete FIRM NAME: 0 LOP-\ LIC. NO­Aw�—J License, V,�\,j rti Signatur LIC. NO.: -able,A�Ier "exein in the license i ber lin C��Bus.Tel.No.: �- k K—1 Mv (If opplic, P Alt.Tel.No.: Address: �--ehj *Per M.G.L.c. 147,s. 57-6 1,security work requires Department 6f Public Safety"S"License: Lic.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)F1 owner 11 owner's agent. Owner/Agent [P7E,R�:I'ET FE FS: $ Signature Telephone No. GGMMG't4WEALTH OF MASSACH. U$ ; . 5 RE'GESTE ED (UTASTER ELECTRICIAN issUES THE ABOVE LICF SE TO: IWESTON SAMPSON CMR INC ANDREW p WHITLEY $ CENTENNIAL DR =, MA 01960-7906� PEABODY I8301 A D7131113 84651 x" s ' PSI4WXWT a Ac R& CERTIFICATE OF LIA BILITY INSURANCE Dia/�3/arooil THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANp CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS BE CERTIFICATE DOES NOT THIS CERTIFICATE OF h INSURANCE DOES ELY Olt ATNOT CONSTITUTE ELY AMEND, F7 CONTRACT OR TBI TWEEN ER THE COVERAGE CHE BSUINOF NSURER(3), AUTHOR ZIEO REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT' If(hQ t:ertlNcate h;ld'' (b an ADDITIONAL INSURED w be Onoorsed, It.5USROGATION IS O the tvlmsand conditions of the policy,pertain). RdI09 may(04utre�art endorsomor L A statement nt on this t0011catO deas not cfonfe prjyhtgl o the oertitioate holder In 'O tiou of suoh endo►semvnt:. PRODUCER1-617-32Q-655 AAmess CONTACT& Dough, Inc. NP.MbE Marguerite Parent 859 PHDNe 617-32Q-6555 2OYd Street No,Eal): 1A10 sui ,kok G 8uika 320 AIL W QuiucSt, MA 02169 A.PIP,Sol HlOhael HaF4i . .. INSURERS)AFFORDING COVERAQE ......_.... NAIC X INSURED _..._ ..... ._. I uReR A: Zurich NA Weston & Samyoon CMR, Inc, INSURER Tom. Co, -..._..__...._._..__.__....._... 5 Centennial Dr. ..._......._.. ..................... Peabody, HA 01960 ursaAyR e: COVERAGES CERTIFICATE NUMBER: 24630056 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE.....ISTED BELOW HAVE BEEN ISSUED 70 THE INSURED REVISION A D ASOVEBFOR THE POLICY PERIOD INDICATED, NOTWITIISTAN DIN fl ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR 0711ER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAW,THE)NSURANCE 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, . . ... ......ADDL SUb TYPEOFINYIIRANCE .•. •... _• ..._... 0outyk 1.00ruCY E- -- .A OENERALUABILttY R LNAti6 OLD 4802961-00 01/01/1 �01/01/13 A COMMERCIAL GENERALLtABIUry EACHQCCURRENCF; S 1,000,000 DAlMOE TO aENYl;l11.ClNA13a'AADE I,R� S,500,000_ . OCCUR .PR€MI�€RIFF&s�yTL�o2 _...._.................._.... NEO ENP jMy one•fieLwn),., $.5.000 _ PERSONAI.dADVINJURY S 000,� �- GfiREOATELINIT APPLIES PER: GENERALAGGREOATE 52:000,000 PRODUCTS• .... POLICY X P 0. L00 �...._.,,.... COLPlePAQO Sa,000,000 AVTOMObILe LlI{b1UlY - COMBWE INOLEU T I ANYAUTO I(Ea ocTJJont)ALL $ SCHEDULED I BODILY INJURY(per porsen)AU S a HIREDAUTOS NON•OWNED ,BODILY INJURY(Potecddam) S.._.. AUTOS PROPERTYDMNOE .... UMBRELLA UAB OCCUR $ .... --- E%Ce83 LIAR EACH OCCURREIK;E .. AIMS-M40E OED ETE..I .. .._ ._ i AGGREGATE $ ...... g WORKERS COMPENSATION . . ... �IANDEKPLOYERa'LARTNI!Y 2099440613 01/Ol/1 Ol/Ol/13 % �VCSTA7U- �OT Ii (OWnAFF"J RtMBEREXCLUOED? CUTIVE Y!N ITORYLIM11TS ER dICER,MEMSERe%CIUDEDI N/A I El EACHACCIQENT Ily�a•dNiuNid)er ., S..1,000,000 fUESCRIPfIONOFWRA71ONSWlow EIDISEASE•EAEMPLOYE 51,000,OOOA I, DISEASE-POLICY LIMIT 31,000,000 �I DESCRIPTION OF OPERATIONS!LOCAMNS1 VEHICLES(Attach AGORD 101,Additional Remark,schodulo,ll mom a ou N ro t � p gtdrod) Bar Proposal Only '. WJ { CERTIFICATE HOLDER CAN , =11 QHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED leACCORDANCE WITH THE POLICY PROVISIONS.AUTHOR ACOI2D 25(2010/05) The ACORp name and logo are registered marks o ACORD RD CORPORATION, All rights reserved. mgardikae 24630056 ." 3 f i i 1 a � The Commonwealth of Massachusetts Department oflndustrial.Accidenis Office Of Investigations .600 Washington Street Boston,MA 02111 www•massgov/dia Workers' Compensation Insurance.A Mdavit: Builders/Contractors/l JectriczanslPluznbers A licaztt forma 'on • Please Print Le 'b . Name Weston & Sampson CMR, Inc. Address; 5 Centennial Drive City/State/lip; Peabody, MA 01960 Phone#: 800'-726-7766 rOl employer? Check the appropriate box: employer with 4. © I am a general contractor and I Type of project(required): Yaes(full and/or part-time).* have hired the subcontractors 6. ❑New construction sole proprietor or partner- listed on the attached sheet. 7. [1 Remodeling d have no employees These sub-contractorshaveg for me in any capacity. employees and have workers' 8 Demolition orkers'comp.insurance comp.insurance. 9. [J,Building addition d,] 5 [] We are a corporation and its 10.❑ Electrical repairs or additions . ama homeowner doing all work officers have exercised their Myself , 11.[f.Plumbing repairs or additions No workers comp. right of exemption per MGL insurance required.]t c, 152, §1(4),and we have no I2 0 Roof repairs employees. [No workers' 13.[] Other comp,insurance required.] "Any applicant that checks box#1 must also fill out the section below showing compensatiott policy information their workers't Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraotors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not those entities have employees. If tine subcontractors have employees,they must provide their workers'comp,policy number. am an employer that is providing workers'compensation insurance for my employees Below is file policy and job site information. Insurance Company Nance: Transportation Insurance Company Policy#or Self ins.Lie.#:- 2099440613 jj Expiration Date; ` � J�oj j Job Site Address:_ �?0 City/State/Zip: h C�lvc, ,Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal . fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKKORbER and penalties a f[me of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of - Investigations of the DIA for insurance coverage verification. �J I do here- , y under t e aims d e ti s of perjury that the information provided alcove is ue and orrect Si afore: Date: Phone#: ^ �_ Offlclal use only. Do not write in this area,to be completed by city or town offciaL ` '{ City or Town: Permit/License# t } Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. CityiTown Clerk 4.Electrical Inspector 6. Other S.Plumbing Inspector 1„ Contact Person.: � r�= Phone#• ---_ ._._ :. ,a 1 r � ra / rl i 1 1/ I r� I r 1 � i ii li a �� rf r � r r ,rjl�rJl/ / f