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HomeMy WebLinkAboutWiring Permit - Correspondence - 24 KINGSTON STREET 3/7/2016 Date�.�.... j �FNORrM��,O TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,88ACHU`y�� This certifies that f .. N �. �o Y ak I�.P@ S �„I u a�I �5 ,,2. .mod.......... has perrriissi n o per�ozY ...... •• ................ L ....:............................... wiring m the building of. . &�.� n•• North Andover,Mass. at .... ......... : .LA.........�....... � � Feel 1 �...........••.Lie.No s• •••• ELECTRICAL INSPECTOR Check# Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. � �ko?),-, � BOARD OF FIRE PREVENTION REGULATIONS I Occupancy and Fee Checked T [Rev. 11/991' (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical(,'ode(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I 1-, .1 2 m (�, I City or Town of. ,"N To the Ins Wi; ,0_AAJ ry e / By this application the undersigned gives notice of his or her intention to perl'orm the electrical work described below. Location (Street& Number) Map: Lot: Owner or Tenant Telephone No.scs. 71 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No '`d Building Permit# Purpose of Building Utility Authorization No. Existing Servici Amps Volts Overhead El Undgrd ❑ No. of Meters New Service Amps Volts OverheadD Undard❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ai(�, �(_10 C )�tl\(4 (Y ---Cyk__ ,k ��Vvl 614- 4A tc ai"y 6 111 Completion of the following table inaj,be waived liv the haspector of //,(.IS. No. of Recessed Fixtures No. of Ceil:Susp. (Paddle) Fans No. of Total I Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above Ei In n No. of Emergency Lighting 2rnd.- ❑ grnd. ❑ Batter v Units J 7 No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS JNo. ofZones No. of Switches No. of Gas Burners No. of Detection and - Total Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I Number Tons JKW No. of Self-Contained Totals: _ I Detection/AlertinjZ Devices No. of Dishwashers Space/Area Heating KW Local El Municipal R Other Connection No. of Dryers Heating Appliances KW Security Systems: "Z, No. of Water No Data. of Signs Ballasts No. of o.of Devices or Equivalent Heaters KW N Wiring: No.of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Te lecommunications communications Wiring:No.of Devices or Equivalent OTHER: .441oeh additional detail ifdesired,or as required b'v 117e Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit Im the performance ol'clectrical 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 ET BOND El OTHER 0 (Specify:) C��Q , Z'C> (ExpiratioQ-Pate) Estimated Value of Electrical Work: (When�-equiredbymuiiicipalpolic%.) WorktoStart: ­jl�'> Inspections to be requested in accordance with Ml:-,C Rule 10. and upon completion. I certify,under the pains anti penalties of perjury,that the information on this application is true and complete. FIRM NAME: fu Inc- LIC. NO.: Licensee; Signature LIC. NO.: (Ifopplicable, enter t"in e nuhnPer,111ne) V I Bus. Tel. No_q��yi_ Address: 47 — e a//) 06 0)C:�(_0() Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not huve the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) 0 owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ " - The Commonwealth of'Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 n Boston,MA 021.14-2017 Ivlvw.mass.gov/dirr Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WPI'H THE PERMITTING AUTHORITY. Applicant Information Please Print Letribiy Name (Business/Organization/Individual):Dinis Electric Inc. Address: PO Box 3955 City/State/Zip: Peabody MA 01960 Phone #:978-531-4471 Are you an employer?Check the appropriate box: Type of project(required): 1.E]I am a employer with 7 employees(full and/or part-time).* 7. New Construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition IF I am a homeowner doing all work myself.[No workers'com .)p.insurance required t 4.r-1 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑✓ Electrical repairs of additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.) 6.F_j We are a corporation and its officers have exercised their right of exemption per MG1.,c. 14.R Other 152,§1(4),and we have no employees.[No workers'camp,insurance required] Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. t 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am air employer that is providing workers'compensatiota insurance for my employees. Below is the policy and job site information. Insurance Company Name:Liberty Mutual Policy#or Self-ins.Lic.#:WC� 3918369 Expiration Date:Aug. 2, 2016 XVSite Address: a copy oft workers mp sattorirp�policy declaration page(showintt�j1etatol policy � (tC ,oe/ 1 ' p g g p y r 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 thepains andpenalties of perjury that the infornurtion provided above is true and correct. Signature: ," �' Date: 1,2(1� Phone#:978-531-401 Official use only. Do not write in this area,to be completed by city or towlr official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector G.Other Contact Pelson: Phone#: AC"R" CERTIFICATE OF LIABILITY INSURANCE 172/29/2016 ATE(MM/DD/YYYY) �/ 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 CONTACT NAME: Rose Munoz EA Stevens Company, Inc. PHONE (781)322-2324 FAX (781)397-7672 A/C o Ext: (A/C.No 389 Main St. E-MAIL ADDRESS: P. O. BOX 188 INSURERS AFFORDING COVERAGE NAIC# Malden MA 02148 INSURERA:Peerless Insurance Company INSURED INSURERB:The Netherlands Insurance Company Coipany 24171 Dinis Electric Inc INSURERC:Peerless Ins 24198 PO BOX 3955 INSURER D; INSURER E: Peabody MA 01960 1 INSURERF: COVERAGES CERTIFICATE NUMBERNaster 2015-2016 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 POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDNYYYI (MMIDDtYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ BKS56083868 8/2/2015 8/2/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea aocidt DSINGLE LIMIT $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OS X SCHEDULED BA3918368 8/2/2015 8/2/2016 BODILY INJURY Per accident) $ AUTOS AUTOS ( X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Experience Mod Factor 2 $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000 000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 US056083868 8/2/2015 8/2/2016 $ WORKERS COMPENSATION X7 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE I I N/A E.L.EACH ACCIDENT $OFFICER 500 000 C (MandatorEMBER y in NH EXCLUDED? WC3918369 8/2/2015 8/2/2016 ( ) E.L.DISEASE-EA EMPLOYE' $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION diniselectricinc@verizon.n SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Electrical Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Thomas Cares, Jr/HK ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(20140) d 00, "O MO 1 f ll.U -MA- MAMMM ITM `'<'1 SSU .S Ii.: -F01.1.UW i NG SE h'f`U MAST I_ -.CTRlCIAN' E1.F.CI-III C..INC .21 M''t) `I`` 2 3955 � }'' 115416 sob N .< ApSS Uf4.,j#R FOLI 0�1ht:QE AfuR E ' E L E CTR I•C I t1 0. A.