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HomeMy WebLinkAbout- Permits #13110-1 - 66 HERRICK ROAD 2/16/2016 Date....,=......: TOWN OF NORTH ANDOVER PERMIT FOR WIRING i This certifies that 7, ' �t , y has permission to perform ....a.:Du or? C.. ..., :.. 2.,i. �........... wiring in the building of, xd . ��. a6....as ........... .. ...:. ................ North A.............................. at ...�� ..... � b..i:..l-61C ........A t • •••••••• �ndover,Mass. Fee Lic.No. �— ..i.. ELE CTRIC AINSPECTOR .................... Check# Commonwealth of Massachusetts Official Use only Department of Fire Services Permit N°. t, Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 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`` 16 City or Town of: NORTH ANDOVER To the bispector of*Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 12-d Owner or Tenant f�C)Vj 9 c Telephone No.9'7 Z-L4 29-2ZXC-�, Owner's Address ("1., tle rlr`i e-V Is this permit in conjunction with a building permit? Yes IV No ❑ (Check Appropriate Box) Purpose of Building t� `r' i � 1�'� Utility Authorization No. Existing Set-vice 2— L) Amps / Volts Overhead 91 Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: t Z Cict �T Conn letion of the ollowin table inay be waived by the Ins ector qf Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets Z- No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets L No.of Oil Burners FIRE ALARMS No.of Zones of Detection and No,of Switches No.of Gas Burnet s No. Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: .......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Connection ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: - Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Ilekl A fG 0' G -"r- Attach additional detail tf desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofpetjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: (5 ",l/Q 120 IZ-t�T• Signatur LIC.NO.: .j Z 5 - (If applicable,enter "ex�npt"i n f re licen n nnber line.) / Bus.Tel.No. Address: ( u Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security Ark requires Department of Public Sa ety"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)❑owner ❑owner's agent. Owner/Agent I PERMIT FEE: $ ,1D-® Signature Telephone No. �� N ®` DATE YYYY)CERTIFICATE LI LIABILITY INSURANCE 07/24/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOTAFFIRMATiVELY 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 BridgeInsurance AssDO. CONME TACT 80 Langley Road PHONE (617)965-1777 FAX .(617)964-1888 2nd Floor E-MAIL ADDRESS- — Newton Centre MA 02459 INSURERS AFFORDING COVERAGE NAIC# NSURER :Travelers INSUREDINSURERS! Brian Froburg INSURERC: 159 Waverley Road N URE D: North Andover MA 01845- wsURERE: 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 TYPE OF INSURANCE ADDL SUBR POLICYMBE POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY 680-008E474619 7/08/2015 7/08/2016 EACH OCCURRENCE _$ 1,000,000 X DAMAGE TO RENTED 300,000 COMMERCIAL GENERAL $ .— CLAIMS-MADE OCCUR MEDEXP(Any one erson $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIESPER: PRODUCTS- $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DFD I I RETENTION S $ WORKERS COMPENSATION WC SRY 1 ITATU- OTH- AND EMPLOYERS'LIABILITY Y I N EEL- ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA E.L.EACH ACCIDENT _$,,,, OFFICER/MEMSER EXCLUDED9 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,.if more space is required) CERTIFICATE HOLDER CANCELLATION Al 002163 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.-All rights reserved. - -- ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD OMMONW9r .TH Of M: OUSET S QOAR �?F E E TR t E Es ThE r01. OWING I ,s Gt'N��x E G ,.OURNF 4` ! ECTR(G i eo #� t��I fed " )VER FAA 0� —: 5Qfi The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02714-2017 �y,�• www.mass.gov/dia Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/OrganizatioiAndividual): 1 ✓4 t—xzo U r �l Address: �� �v N`l V rr t_y 9b City/State/Zip: /y, )Qt Vb0 v r" Mn Phone#: $ �1�7 Are you an employer?Check the appropriate box: Type of pre' .t(r'equired): 1.Q I am a employer with employees(full and/or part-time).* 7. ❑Ne .isft action 2.[4 1 am a sole proprietor or partnership and have no employees working for me in 8. Fj R ideliAg any capacity.[No workers'comp.insurance required.] 9. ❑Demolition IF]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.nX Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Fj Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.❑Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing ivorkers'compensation insurance for•my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: ' J Expiration Date: Job Site Address: &(o H t V-94 C k- 0�5 City/State/Zip: Iv" 4,j t y V E(2- 1 d 1 V 115 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thep ' s aridp alties ofperjury that the information provided above is true and correct. [6 Signature: �"dl Date: Phone#: Official use only. Do not write in this area,to be completed 7cityorwn official.. City or Town: Pse# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: