HomeMy WebLinkAboutWiring Permit - Permits #12691-1 - 32 KINGSTON STREET 9/17/2015 9
v
Date„�..�..�.
OF N�RTN `-
`' TOWN a N OF NORTH AN')OVeR
PERMIT FOR
CHusEt4
F,y
This certifies that
.. .
has permission
e
o performi� ........................
'v"ing in the.buildin .5 ...-1.
�� r
.......................
at ......
Fee ........... .....,
.....Lic.No, c•�cj North Andover,Mass.
-12 ..............................
CIl@CIC# - EL"TRI AL INSPECTOR
Official Use
only
Pmmd No.
beparlm,,a
TIONS Occupancy and Fee ChcCheckedBOARD OF FIRE PREVENTUN REGULA v E L_
FOR PERPA17 TO PERFORM ELECTMCAL VVOCIRK All%Ymk to be performed W amw&we with the maeam,,,ENWO We WCh 527 CMR 1210
(PLEASE PRINT IN IAIX OR TYPE ALL 17\117OR MA TIOA)
City Or Town of: A�o_\,N, TO 1,/?t,
171�d g i v e s �At, 4 By this application we unn,g 0., Ids or hit 0110-1-1-ti-0-11 to pelfomn ['ht e],-Cjl-jcaj 01j,
described bolo„.
L,0cadoll (Street&Number) ei
O:v),n er or Tenant
TelephoneNo,
pliwo___(III U+01_�l 0
01�vner's .e�Idress Q&.%.
Is this permit ill CoQuncdorl wah a bulwing pumu? No LV (Checkiippropriate. Box)
Purpose of Building. Urilih,Authorization No.
Existing Service foe
_ !�) A.mps A Volts Overhead
----
New Sel-vice j i(!�_ j Undgrd No. of Mears
:amps p s Volts Overhead I
4q_La�O 11 n d g r d No. of Mears k
Number of Pecders and AMp2City
Location and Nature of Proposed Electrical Work:
o 4;
MM'ha warned1)), ,,a
No. of Recessed Luminairesof ceil.-Susp. (Paddie) Fans 'No. T o
No. of Lurninaire outlets
No. of Hot Tubs
I Generators KVA
Aw, In.- rl�
No. of Luminaires 'irrril o o _T)5�). oTE ifie�geTi c)� 1�
mg P rn d, IB2(tery 1-Inas=E N
No
No. of'Receptacle Outlets
of OH Burners [IaRg ALARMS IN, 9 We,N,1)
No,
o
o, of Switchesu.rners and
Devices
No. of Ranges No. of Air Cond,
Tons i-No. c�,f Alerting Devices
_tP rnF)
ll\:,o, of Waste Disposers . IS)11—Ifl t_)",
Iona!,: ..........................4 Is. Stecdon/Aferline Devices
No. or Dishwashers
Spac&Awa Heating IOV —Unicipal
INo. of'Dryers `----- heating Appliances._._..___
KNV
0. elf0. or E
.fro. of IVV
at at
Signs B2110. S
:''oAf DhAes or Ewkwnt
cc,M i
No. Flydrvnrlavne Bathtubs NwofMotors Toni! HP —
No. of Devices or
OTHER:
or as
We of) lectrical �ulr�aby'ihe.
'$ (01han requirod by munidpal policy.)
Wak m Sm 10 10SPAWIS to be requested in accwThncc with MECRuic I(), aj-,c] topgn Corrj_ tt n,
)I io
INSUR--kiNCE COVERAGE: U05H waived b�±c ovvne--7 no pt:-Init for the performance OfcLCT:jcaI work may ay issue u n.!rs
le Hcensw provides proof of hqbility inswance includiag"aupytod wgratkn"cove.mg-, Or its substantial equivalen t.
w0signed wrimes Am mwh Ej
kNC
C cov -0 is in Arco, and has F01kc!ynggsamt M A, ,,p N,q Mce.HECK ONE TSUI�_- E 1�0 ---BOND
IceNQ under the pubs and penalties of vedull, qq 'on a -* 7
I
Q
on 0 weand conT s e,F11'0 NAME: t— c
at,,eU:,X16 cense no, oar W) N
ASe : ogo1jus. TeL F
Per M.G. 7FCS I A ALL Tel, WI
Lin No,
INSUR-kNCEWAIVERr I two Rvmre 1ha:A2 Licmmee does not have ihn
required by 1a,v. BY my Qawm below, 1 hysby woiNa ±4 requhamcm I ain the nop one) I-] ov,,Fler
In a to re Te 1 Dn e.No.
IT PT
AC"R"� CERTIFICATEF' .OF LIABILITY INSURANCE' DATE(MMIDDn-rN)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T)it~ CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NE'GATIVE;4Y AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOER NOT CONSTITUYE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRE35NTA71VE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTAk1; If the Certificate holder Ia an ADDITIONAL,INSURED, the pollDy(I�s)must b. ondpraod, If SUOROGATION IS WAIVED, subject to
the terms and cone 110u s ni the policy,DQrtain pnliDtas rosy requlrS an SndorBOment, A Statement on thta cortlflcate does not confer rights to tho
cortlflcatB holder in Ilsu of such Bndoraoment(a),
PRODUCER
Neill&Neill Insurance Agency Inc AMP, David harry
862 Ft(verdale street P}1DN Q K71• (413)732�3137 r"' " rAll West Springfield,MA01089 a.M IL — — A/C No):(A13)73t-662s —
ADORC
INSUA�iR 8 AFPORDINO COV61tA0G _�
IN9URE0 Michael Farelil Electrical ._._ IrlauRaRA, 5lateAuto'InauranCe G_ampany NAtca
9Applewood Lane INSURQRG: Acadia Insurance Ccl ��' 8TA
Methuen,MA01844
INSURE
INS RPR 2 i
COVERAGES JJNSURERF:
CERTIR'ICATE NUMBER;
RE
TH;s IS T'0 CERTIFY 7HA7 THE POLICIES OF IN&URANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR G pOLiCY PCAIOp
INDICATED. NOTWiTN3TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY GONTRACT OR OTHER DOCUMENT Vv11H RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DC$CRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLU3fON5 AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REOUCt D BY PAID CLAIMS.
1NSR -----------...�.�..
TYT!tlF IN9UHfWCE �'
A OE14EPAL LIABILITY FOLICYNUMNgR M DI M MO ---'-
90fy27abt317 06%10 72015 08/10/2016 L1MITs
CCN.MCRCIALOENCRALLIABILITYcuoccuRRENCe _ 1,000,000
TH
cLceag.Mgok LX'UCUVR 'n°SAAI:M 6 �—�s 50,000
LM CXP(Anyvn�oasvn) -I 6 - � ' S,000
E ��_Y`u�y^---_ PERSONAL 8 ADV INJURY S_ 110001000
I G".N'LAGUAE6A_TELIMITAPPLIF.SPER: - OENERALAOORCOATfi S ^2,000,000
POLICY PR _ LOC PRODUCTS•COMP/OP A00 b 2,000,000
AUTOMOa1LE LIABIUTY I $
ANY AUTOALL
_._ AUTOS ED SCHEDULED BODILY INJURY(Par panon) $
— AUTOS
HIRED AVT08 NON'OMCD DODILY INJURY(Par ocddrnq b --
AUTOS PRU RbRTTY UAMAUE
UMBRL'LLA LIAe
OCCUR S
9xC888 UAL CLAIMB-MADE i EACH OCCURRENCE
DEO �ACi(3REQATB �� �S ^----
FB WORAQRSCOMPENBATION I
AND CMPLoytna'UASIUTY WC-20.20.0014B1-US U3/20/2018 03/20/ 0 S
ANY DROPRIE7'OR/?ARTNER/ExECUTiva YIN E IOTH;I"" - ^--�^
OFFICFRRdt<MBCREXCLUDSD7 U NJA I PR
(Mrndtlory In NH) C.L.EACH ACCIDENT 6 __ 100,000
11 .1 dIPTO OP0 E.L.OISEASF—RA MPI.QYE6 5��--100,00E
09L�RIPTION OF OPERATIONS Below _ _ `
E.L,DISEASE-POLICY LIMIT S 500'000
i
l :
ORECRIPTi4N aF OFIRATIONS J LOCATIONS/VUHICLE9 (AerCh ACORD 4oi,AddlUonrl Remoda SchrduU,Ir moo a0rer Ir r�pUlrvd)
Foxed to: 978-682.1480
CERTIFICATE HOLDER
CANCELLATION
Town of North Andover SHOULD ANY OP THE A8GVe DESCRIBED POLICIES 8E 0ANCEL1.Ep BEFORE
1600 Osgood Street, Buiftling 20 THE.EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVERED IN
Suite 2035 ACdORt3ANCE TH THE POLICY PROVISION&
North Andover,MA 01845
AUT1iORIaDREP 'se AITVI ;
I
I �
ACORD 26(2010/06) 1980-2010 ACORD• ORPORp All rights reserved.
The ACORb name and logo are registered marks of;ACORD
17ze Cominonwealtlz .M o
,fas sachusetts
h
Z Department oflndustrictlAceidents
Y Congress Street, Suite.100
.Boston,.MA 02114 2017
wwwanass.go v/dia
Workers'Compensation Insurance Affidavit: Builders/Contractois/Electricians/Pluznbers.
TO BE FILED WITH TIM,PERMITTING AUTHORECY.
A2 licaut Information
Please Print Le ibl
NaMC (Business/Organization/Individual): c
c
Address: � A PN�_W)C;t;)d_ _C,t
City/State/Zip: ,
-- "`
[2.n
e ycyr an cmployer?ChecEc the aplii•opriate box: -------
qd
/ 1F9,-
pe of project(required):
T am a employer with .: employees(full and/or part-time),
I am'a sole proprietor or partnership and have no employees working for me in New construction
any capacity.[No workers'comp,insurance required.] [�Remodeling
IEl I wn a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑Demolition
4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. 10 ❑Building addition
Twill
ensure that all contractors either have workers'compensation insurance or are sole
11.(0`F,lectrical repairs or additions
proprietors with no employees.
5.E,I am a general contractor and I have hired the sub-contractors listed oil the attached sheet. 12'0 Plumbing repairs or additions
`These sub-contractors have employees and have workers'comp.insurance,t 13.[]Roof repairs
6.[]We area corporation and its officers have exercised their right of exemption per MGL c, 14•❑Other
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.
f 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.
f am an employer that is providing workers'compensation insurance for my employees. Belo}v is the policy and job site
information.
Insurance Company Name: ' /Ve 1
Policy#or Self ins.Lic.#:_ 'ta.� y1^ (a Cr -r Expiration Date l
Job Site Address: _., !� ✓� City/State%Lip: G�
Attach a copy of the workers' comp—p nsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§2.5A is a criminal violation punishable by a fine up to$1,500M
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.
f do hereby certify under tlllepal andpenalties ofperjury that their formationprovided above is true and correct.
Si mature: — �� � i�,, Date:
Phone#_ �33 .- �011�
ricial use only. Do not ivrite in this area,to be completed by city or town official,y or Town: Permit/License#ing Authority(circle one): V
L.Board of Health 2.Building Department 3.City/Torun Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: _ Phone#: