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HomeMy WebLinkAboutWiring Permit - Correspondence - 1407 GREAT POND ROAD 11/6/2014 . � � Date .. ..... ..................... �o�.�•'`, ,:,'tioo TOWN OF NORTH ANDOVER 3 n PERMIT FOR WIRING jV This certifies that ...... .. ems:. .. ....................................................... ........... F d has permission to perform ............... t � W wiring in the building of € ` 1 I . olre l � ' f rth Andover,Mass II f at ....: B .... l l .: %...........e....... ...... Fee......... .Lic.No. ......... .... ... """"" EL CTRICAL INSPECTOR Check# n I Commonwealth Ofa�JJTe of Massachusetts Permit No. I y Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. i/o7j (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NIEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I 1 11. - / -- City or Town of: NORTH ANDOVER 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) 4 C)-j ,,I Pu vid IQ Owner or Tenant riG 0(1 Ir 01)e r yi,o r o c Telephone No. Owner's Address cA yvt-p Is this permit in.conjunction with a building permit? Yes I 1 No ❑ (Check Appropriate Box) Purpose of Building• ( ^,go 1 0 , 4?CA i-vz, (I Utility Authorization No. Existing Service- Amps V Volts f Overhead ❑ UndgrdF] No.of Meters New Service Amps Volts ❑Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: no ex ktl�, (P-0% Completion of the following table may be waived by the Inspector No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above D In- No ot"Emergency Lighting No.of Luminaires swimming Pool grnd. ❑ grnd. ❑ Batter v Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS lNo. of Zones of Detection and No. of switches No. of Gas]Burners No. Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pump KWI.......... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑F1 municipal D other Connection No.of Dryers Heating Appliances I.11W Securi Systeevi s:* No.t 0 f Dces or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts . No.of Devices or Equivalent eco mmunications Wirin : Nn.Hydromassage Bathtubs No.of Motors Total IW TelNo.of Devices or Equivaglent OTHER: I Attach additional detail if desired,or as reqtilred by the Inspector of Wires. Estimated Value of Electrical Work: 0 C........ (When required by municipal policy.) Work to Start: I I--6,..1 Cy Inspections to be requested in accordance with NIEC 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 0 BOND D OTHER D (Specify:) I cerilry, it n(let the pains an dp en allies ofp eijuiy,that the information ation on this application is tru e and complete. FIRM NAME: Le u kS LTC.NO. <�c�psee� -�6&0.4 Le,(�, L. Signature LTC,NO.: alicaNe,enter "exempt"in the license number line) Bus.Tel.No.: Address: Alt.Tel.No.: 5 5 *Per M.G.L c. 147, s.57-61,security work requires Department of 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)D owner .❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name (Business/Organizati6n/Individual): ]', Address: L7 A City/State/Zip: N , 6)t,?45' Phone 4: Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. [11 am a general contractor and 1 6. n New construction employees(fall and/or part-time).* have hired the sub-contractors 7. E]Remodeling 2.El I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. workers' comp.insurance. 9. 0 Building addition [No workers' comp.insurance 5. [J/*c are a corporation and its required.] officers have exercised their 10.EJElectrical repairs or additions E] 3.❑ 1 am a homeowner doing all work right of exemption per MGL ll.n Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.n Roof repairs insurance required.] 1 employees. [No workers' 13F] Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. am an employer that isproviding workers'compensation insurance for nay employees. Below is thepolicy and job site iforination. isurance Company Name: olicy#or Self-ins.Lic. Expiration Date: :)b Site Address: 140 1 0-r"4 Adl. city/state/zip: rj ,ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 C up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Ivestigations of the DIA for insurance coverage verification. do hereby certify unrler the pains X andP alties of perjury that the inforinationprovided above is trite and correct ignature: Date: [lone Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit[License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: COMMONWEALTH OF MA5:5AC:14 Ubt:1 15 130Ai�p 0� ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS REGISTERED MASTER ELECTRICIAN a J-G'LEVIS ELECTRIC CO INC JOSEPH G LEVIS 160 PLEASANT ST v J NORTH ANDOVER MA 01845-27o6 9979 A 07/31/16 27339 JGLEV-1 OP ID: KM �►ce�►rz®° CERTIFICATE OF LIABILITY" INSURA CE DATE INSURANCE05/12/14/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must he endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Phone: 978 688 8829 NAME: Michaud,Rowe And Ruscak Ins, Fax:97$ 557 2130 PHONE FAX P.O.BOX 188 INC,Ne,Ezl{: I INC,No): North Andover,MA 01845 EMAIL Lawrence R.Michaud,CIC ADDRESS: INSURERS AFFORDING COVERAGE NAIC 11 INSURER A:Preferred Mutual Insurance Co. 15024 INSURED J G Levis Electric,Inc. INSURERS: c/o Jack Pare PO Box 685 INSURER C Methuen, MA 01844 INSURER 0: INSURER E: INSURER F: 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 PAID CLAIMS. lLTR TYPEOFINSURANCE ADD��WVDD POLICYNUMBER MMIDDNYYY MMDDTYFF POLICY YYYXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMA COMMERCIAL GENERAL.LIABILITY BOP0100718051 04123/14 04/23/15 PREMISES Ea occurrence S _ 50,000 CLAIMS-MADE OCCUR MED EXP(Any one person) S X Business Owners -PERSONAL BADVINJURY S 1,000,000 GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 POLICY PRO'IFCT El LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED SCHEDULER BODILY INJURY(per accident) 5 AUTOS AUTOS _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTO$ per accidenl S UMBRELLA LIAR OCCUR EACH OCCURRENCE I S EXCESS UAB CLAIMS-MADE AGGREGATE Is DED RETENTION 5 I 15 WORKERS COMPENSATION ( WC STATU- OTFI- AND EMPLOYERS'LIABILITY YIN TpRY LIMIT ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? NIA -- — - (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below L-.L DISEASE-POLICY LIMIT S PROPERTY 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space is required) Electrical CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 120 Main Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD