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HomeMy WebLinkAboutWiring Permit (s) - Correspondence - 1160 GREAT POND ROAD 8/7/2014 i F ( Date .............................. I( d �NORth I TOWN OF NORTH ANDOVER * PERMIT FOR WIRING CHUg�� It This certifies that I b n •• t r has permission to perform y .............. g in the building of A >c �L - Wll'lii L'� 4 . .• ......... at t v """ Fee t 0 North Andover.... >Mass. Lic.No FELECTRICALINSPECTOR Check# � P � _j _ �' (flImnWnwealM ol MaddacLetb Official UseOnly, Permit No, Serilked - t:Z, ca, Ocpanc y and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Revcu , 1/07] (leave blank) 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 INK OR TYPE ALL INFORMATION) Date: F,Ll C?/�--o J v, City or Town of: NOt-O-) Ar"00 Vo,,— To the Inspector of Wires.- By this application the undersigned gives notice of his or her intention to perform the electrical work described below, Location (Street& Number-)_//6() luoj-j-,k) "vonler- MP 0/g 1-15- Owner or Tenant J67 STelephone Owner's Address Is this Permit in conjunction with a building permit? Yes No F-1 (Check Appropriate Bose) Purpose of Building_---- Utility Authorization No. Existing Se1.v1r(!e­jF0,--�- ii �" volts Overhead F1 Undgrd-R- -/ No. of Meters New Service .26� Amps 'VeZ,11 ­17> Volts Overh ad Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work; Comlethe ollolvin table may be waived by the Inspector 0 OTIS'. 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 /�7�o�ve ❑ 11- -1 No-, oT Emergency Lighting I Swimming Pool 'I El�!- ❑I No. of Receptacle Outlets gi-nd. -grnd. Battery Units No. of Oil Burners FIRE ALA" Zones iEol !fZ01- No.of Switches No.of Gas Burners N7o of Detection and I ires Swimming m! of Lumh'i�_ of Receptacle Outlets [No. of 0 Initiating Devices No. of Ranges No.of Air Cond, No. of Alerting Devices No. of Waste Disposers TTe—atP1u-1n-p-7.qm b e r Tons W No. of Sel -Contained Totals�, ............ITons .......... Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Ej Municipal D olier Connection tIer No. of Dryers Heating Appliances KW Security—f�t eim s�, Equiv alent I No,of Devices or Erquiva ent No, of WTtj7,— No,of No, — Heaters KW Data Wiring: igns Ballasts T- No.of Devicesor E mvalent -omassage Bathtubs No.of Motors Total HP elZ�communiFationslv iring: I� No, Hydi r n OTHER: No.of Devices or Equivalent Estimated Val Attach additional detail tfdesired, oras required by the Inspecio-1 of-111111, Value of ylectrical Work: (When required by municipal policy,) Work to Start: ? R, _ Inspections to be requested in accordance with MEC Rule 10,and upon completion, INSURANCE C VERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue [111leSS the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND 7 OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: j— )0_ � .�rij LTC. NO.AILLa I Licensee: 'Y66 C'/,.I-� "" Signature -0 LTC, NO,&Q,� (1fapplicable, enter "exempt �n the ice se nian er line, Bus.Tel. No.: &0 Address:(o�­VA V-o� *Per M,G,L, c. 147,s. 57-6 1,security work requires Department of Public Safety"S"License: Lie,No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance cover—age normally' required by law. By my signature below,I hereby waive this requirement, I am the(check one) 171 owner El owpers agent. Owner/Agent Signature Telephone No,___I PERMIT FEE; $ z 4 "21L i A6� DATE( CERTIFICATE OF LIABILITY INSURANCE F8/8/201 M/DDIYYYY) 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 endorsements. PRODUCER NAMEA T Diane M. Lusardi, CI Eastern Insurance PHCNNo E t:508-586-5432 a/c Ne:5 - 87-49 500 Forest Avenue E-MAIL Brockton MA 02301-5749 ADDRESs:kh geld(2easternin rance. o INSURERS)AFFORDING COVERAGE NAIC# INSURERA Valley Forge Insurance Company 0508 j INSURED INSURERB:St Paul Fire&Marine Ins CO 24767 Island Lighting&Power Systems Inc INSURER C:National Fire Ins of Hartford 20478 6 Hill Street Norfolk MA 02056-1628 INSURERD:A.I.M.of MA 33758 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1992633727 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 PAID CLAIMS. INSR TYPE OF INSURANCE ADD UBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER 1MM/DDIYYYY1 fMMIDDIYYYY1LIMITS A GENERAL LIABILITY Y Y 5091052136 /28/2014 /28/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENT�_ PREMISES(Ea occurrence) $300,000 CLAIMS-MADE K OCCUR MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 r GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 1 POLICY X PRO- LOC $ C AUTOMOBILE LIABILITY Y Y 5091052105 /28/2014 /28/2015 Ea accident 11,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) F —NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident $ $ B X UMBRELLA LIAB X OCCUR Y Y �ZUP-15N25627-14-NF /28/2014 /28/2015 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000.000 DED X RETENTION$10,000 $ D WORKERS COMPENSATION WC 400-7025872-2014A /28/2014 /28/2015 X VVC STATU- OTH- AND EMPLOYERS'LIABILITY YIN O Y LIMI S ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1 $1,000,000 A Lsd/Rented Equip 5091052136 /28/2014 /28/2015 $200,000 $1,000 Installation $ 50,000 $2,500 Riggers $ 50,000 $2,600 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) A WORKERS'COMPENSATION CERTIFICATE WILL BE SENT DIRECTLY BY A.I.M. MUTUAL INS CO.Additional Insured status provided when/-equired by written contract per GL forms G-140331-C&G-300804-A. CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD Fold,Then Detach Along All Perforations v COMMONWEALTH OF MA SEIHUSETTS BOARD n>r ELECTRICIANS I ISSUES THE FOLLOWING LICf'NSE AS A W R>rC i Sl' 'kED MASTER :EtECTR I C I AN ISLANp' LIGHTING AND POWER SYSTEM !" DAMES M ONE`. `N 6 HILL ST NOFtFOLK MA` 02056 1628 142 A 073}d16 : 96526 Fold,Then Detach Along All Perforations e- OMMONW ALTH OF 4RAF{p nl EL E �i I C I`ANS ISSUES THE FOLLOWING t'f�ENSE AS'`A E JOURNEYMAN ELECTRICIAN JAMES>M ONE IL 109 ATHEAM ST M1..LiTQN MA 02186 1202` 25775`