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HomeMy WebLinkAboutWiring permit 12720 - Permits - 39 HIGH STREET 9/8/2014 Date. ... ....... ....... AOR'r 3a :'•�oo� TOWN OF NORTH ANDOVER o m PERMIT FOR WIRING ssACHUsrc This certifies that ..... `............ ....'.......... f .......:::. < has permission to perform '.. .`;. ,' f ......... , wiring in the building of..�......r : ................................................................. at . , ..................... ........ t.:. n ;.. rt Andover,Mass. Feec'".... Lic:No " .... .,d . ELZ5��ICZINS�P�E�C�T�ORCh eck# Commonwealth of Massachusetts Official Use Only Permit No Depart nt me of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NMC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPBALL MFORM TION) Date: City or Town of: NORTH ANDOVER To the lnspelctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below, Location(Street&Number) 3? �/V, - Owner or Tenant <�,q,­11S), Telephone No.(�`7/) Owner's Address Is this permit in conjunction with a building permit? Yes [I No P (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] Undgrd[I No.of Meters New Service Amps Volts OverheadD Undgrd F1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .460771'e I)i1l;el 4'AO245' 41' 41 16 ZiCLz Completion of the followingtable may be waived by the Inspector of Wires. f. No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminalre Outlets No. of Hot Tubs Generators KVA NO-50-FEmergency Lig ting No.of Luminaires Swimming Pool Above n In- ❑grnd. grnd. FaerUnitsNo. of Receptacle Outlets No.of Oil Burners IRE AL of Zones No. of Switches No. of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump 1.NPM!?.YM Tons KW No. o Self-Contained Totals: Detection/Alerting Devices * No.of Dishwashers Space/Area Heating KW Local[IMunle'PtP' F] Other Connection y Systems:* No. of Dryers Heating Appliances KW Securi No.t of Devices or Equivalent No. of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices orEquivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: //i/ E upon completion.,/4/ _Inspections to be requested in accordance with M CRule, 10,and po INSURANCE 0-U-VERAGE: 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 P"BOND E] OTBERE] (Specify:) I certify, under the pains and penalties ofpeijuYy,that the information on this application is true and complete. F IRM NAME: ' , LTC.NO.: A110, Licensee: Zb, 'ZAt' Signature I/ LTC.NO.: (Ifapplicable,enter "exetnpt"in the license number line) Bus.Tel.No.: Address: au "T' 1W,,ti,,xr � /� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,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 coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)[]owner El owner's agent. Owner/Agent n I Signature Telephone No. AMIT FEE: $ The Commonwealth of Massachusetts - Department of IndustrirclAccWn* is Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nance(Business/Organizationdfndividual): Address: r' : )w An =d� tm City/State/Zip: /" Phone#: Are yojx,an employer?Check the appropriate box: Type of project(required): 1.0 11 I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a solo proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. 9 y p ty. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t comp.�insurance required.] 13ees. [No worers' .❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: " Policy#or Self ins.Lie.#: tY1#w/) 0,14 °% '" yry Expiration Date: Job Site Address:, 7"" , t}a °'e . )"' ('0 "Y i LL City/State/Zip: 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 e. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under the pains andpenalties ofpeijury that the information provided above is true and correct. - Simature• Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitfUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: " 1 ELECT-2 OP ID:GM CERTIFICATE OF LIABILITY INSURANCE DATE /2013 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 endorsement(s). PRODUCER Phone:401-558-0101 CONTACT A.W.Bucci&Assoc.,Inc. 1350 Division Rd.,Ste.101, Fax:401-558-0167 AHONNo Ext: A/C No West Warwick,RI 02893 EMAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:St.Paul Travelers INSURED Electro Standards Lab.Inc INSURER B:Beacon Mutual Insurance Co. 36 Western Industrial Dr Cranston,RI 02921 INSURER C;Merchants Ins.Co.of NH 23329 Cr INSURER D: 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. INSR ALDDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE 1 SR WVD POLICY NUMBER MM/DDNYYY MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY ZPP-11T17366-12-15 11/01/2013 11/01/2014 D AGE TO RENTED PREMISES Ea occurrence $ 300,000 CLAIMS-MADE J OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 C X ANY AUTO CAP9267872 11/01/2013 11/01/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERT YDAMAGE $ AUTOS Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE ZUP-11T17378 11/01/2013 11/01/2014 AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVEY/N 3174 11/01/2013 11/01/2014 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? F-] N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD