HomeMy WebLinkAboutWiring Permit - Permits #12997-1 - 160 FLAGSHIP DRIVE 1/4/2016 Date
0 TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
CH A
This certifies that
.................................................................. ..... ...............................
has permission to perform
wiring in the building of...
.......... .. ..........................................
at .....VaQ.......
V.........
.......................North Andover,Mass.
Fee........ No.
.................Lic.
................. ...........................
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Check# INSPECTOR
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(f1mmonwaa11411 V14jachu6oM Official Use Only
/7 Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev...1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code MEC),127 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)TION) Date: � C(
City or Town of: 11ILVO-41, 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)_
-
Owner or Tenant -2- Telephone No,
Owner's Address
Is this permit in conjunction with a buildiniJ
g peKmit? Yes F-1 No (Check Appropriate Box)
Purpose of Building (X)f)(AVV\QA1c'kV Utility Authorization No.
Existing Service Amps Volts Overhead 0 UndgrdO No. of Meters
New Service Amps 1 Volts Overhead D Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
V
vd'
yo
conplefioLo j
of may be ivaivedky the Ins Wires,
No. of Recessed Luminaires No. Of Ceil.-Susp.(Paddle)Fans No. of Total
Transformers KVA
No. of Luminaire Outlets No. of Hot Tubs
Generators KVA
No. of Luminaires ove In- ❑ o. o mergency ig Ing
Swimming Pool grnd. - rnd. Battery Units
No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo.of Zones
No. of Switches
No. of Gas Burners N-0--o-f-'Ue—tecfiOn a—nd—
Initiating Devices
No. of Ranges No. of Air Cond, TonsT— No. of Alerting Devices
'
um er OHS No. of Waste Disposers cat amp 0. 0 e - ontame
- Totals: Detection/Alertin Devices
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No. of Dishwashers - Space/Area Heating K IW Local F-1 Connection 1771 Other
No. of Dryers 'Heating Appliances KW Security stems:
No, of water INO. 01 No.of Devices or Eguivalent
No. ()r—
Heaters XW g.
—Data Wiring:
Signs Ballasts No.of Devicesor E uivalent
No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wirn m
1
OTHER: No.of Devices or E uiva5 ent
A ttach additional detail if desired, or as required by the Inspector of Wires,
Estimated Value of Electrical WorO,101",A (When required by municipal policy.)
Work to Start: 1. Z15' _ Inspections to be requested in accordance with MEC Rule 10,and upon completion,
INSURANCE COVERAGE: Unless waived by the owner,110 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 Q' BOND ❑F-1 OTHER E71 (Specify:) ( —
fl)erjury, that the infonnation Oil this UPPlication is true and compkte.
I certlfy, under the pains andpenafties o
FIRM NAME:-1�c), A& s LTC.NO,:JLI�c-
Licensee:
Signature LIC,NO.: 24
(If applicable, enter exempt tin,1 6 icense i umbe)-line)
be�/, ��, )T
Address:
Bus. Tel.No.:--S-
Alt. Tel. No.: Ul
'Per M,G.L, c. 147,s, 5 -6 1,security work requires Department of Public Safety"S"License: Lie,No.
OWNER'S INSURANCE WAIVER: —3--i�
I am aware that the Licensee does not hate the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the(check one)® El owner's agent.
caner gent
Si nature
Telephone No. PERMIT FEE.- $
Got4f1momwEAL.TH OF MASS�kCFiI.�S ITS
s : H.
BOARD OF
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE
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AS A R;EG JOURNEYMAN,.,ELECTRICIAN`'
tir
hNNEilH M THOMPSON
16 EARLY Rb W
M^ ^l;rit! ;218
t�"4 `OM�V10'GV1N CL1 H 01)r 5en's; k`»
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}< Y:-F.S'51E8F1'1~- E'ALL.0.4JI;NG�i `fC� S' A'
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SSCO-000355
Frederick W Davis `
6 Webb Place
Saugus MA 01906
04/04/2017
DAVCSEC-01 LCARUSC
"OR _ CERTIFICATE
OF LIABILITY INSURANCE FDATE(MN1D01YVYY)
I HI5 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS Up6N TI•IE 0ERTIFICATs 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($),AUTHORIZED
REPRESENTATIVE OR PRODUC9R,AND THP CERTIFICATE HOLDER,
11APORTANT: If tho certificate holder is an ADDITIONAL IN9uREp,the policy(los}must beorso endd. If SUBROGATION IS WAIVED,subject to
flee tormS and Conditions of the policy,certain policies may roquire an ondorsoment, A statomont on this certificate does not confer rights to the
curtiflcato holder in lieu of such endorsement(s�
4'iGt CLR IboNlAO"T --w--
Sa1om Five Insurance Services,LLC hAhlkl _ w
446 Main Street PHONC I'FAX ^-
Woburn,MA 01801 LAMANo,C U:(7E1)933�31E10 tA1C,No 781 533.9048-
A C Si insuranee,servico5 salomfive,com
INSURERIS)AFFORDING COVERAGE NAIL a
If,8..Rco _ ._�__ _ _ INSURER A:Everest Insuraltece Company
INsu*R a:Travelers Cos&Sure_ ty Co,of AM �31194
Davco Security Systoms Inc INSURER c: r `+
*PO Bo1S, 20 01908 INSURER D tSaug
IN$URFR F.;
-C:CVERAGES _ CERTIFICATE NUMBER: REVISION NUMBER:
I I r' 13 1'Q CL Kl'IwY THAT IHt: PC1I.ICIES 4F INSUWANCL-.7S'r'ED E36!OVJHAVF Hl NN ISISSUF;)�)'O t Hlw INSUR2 ,O NAMFiO A'86Vi f6 THe 06ucY FER.U`J
.0�,A"'ED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCLMENT'N)TH RESPECTTO WITCH T)liS
I ICATL. MAY 6C 19SUr0 OR MAY PERTAIN, THE INSURANCE ArrOROCD By 'rFIC' POLI6IGS DE:8CRi6CD HGRL!N IS SUBJECT "0 ALL THt IhRMS
/(.'I(J1d1ONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE:8F.FN RL DUCF..t)HY PAID Ct AIMS
�rL! TYPE OF INSURANCE _ „_ INS17„1Ny0 HOLICY,hl1M®CR I LI Y ,
A I X COMrd@RCIAL O[NERAL LIApILITY "' (MM/00lYYYY) (M3
U6
5-11 LIM1IITS
� Y � kr'+t;HO(;CJFIkhACE � 1,000,OOG
I
r• CLAIMS MADh L'�OCCUR X 61GL007281-161 06/16/2018 00/16/2016 NRrAdt�r'S;F0 uu:ettm•ta•j 3 1501000
! Ml:u kXt7 tAny une peru••, t 5,00C
— PrR.tOVAI aADVIN.URr 5 11000100t
t?cN'LAOU!t6UiCl'EUMIt All'1�6P;;k.
"x'I�t)„ry�!I,JC R� I GaNHrtAL..caCltEc;n!k s 2,000,00(
I 'v PROWO.-S-001'JP/CPAGt; 5 21000100t
r01
I AUTOMOBILELIABIL17Y r I Ih1tT •5 1 0 t I I ,•LCn nrelM.+ml , 00,000
"^�f0 8A7E888021 08/16/2018 08/18120161uC>uILYIN.,�stY(f+crlx,�nn, S
O'aNEiO � I $C'rIECU1.EJ
r\UrDS ! HO71LY IN•!CRY 0'6r 4CGt!0"t! S
X X.NON-OWNrr,
mLC AUT09 ."..I AU'OS !grlpli TY r)AMA1• s'
X limmRCLLALIAa X GtGUUIt� ~y,Yv••M•"• "..Y_-..��e.rtl:"OL"041tRt:vCC S 8,000,000
;A UOP3!)LIMA Cu,.Ms MAuk IS1 CCO02642-161 06/1612016 06/16/2016 ~~
Of u X r RrYFN1'ON 3 10,000 nGC� RL CJty lii -� A $,000,000
WORK645OOMPENSATION "._—,'•'••.•.. I�X' �ii• �a
Al-109MP4OYeK8'LIAHILIIY Y1N
B At Y NHL)NHIcTUH,PARINbkih.Xi-CU'1'IVr U87E861801 06/16/2016 06/1612016 + _
t�• CI R MI MBRH rXCl.U0VD4 N N/A I I ACn ac cltleNT S 1,000,000
tM1tandotory In NH) -_-
.•t.aI M10 tb.,.aum � ,. ,n,HrA>~e.1'A rMal nvrri s 9,Otl0,0e0
.,,I,-CM1�M S2r CgArns n,tm _
-- — r 7 on+rA r•=<),IWv1,Wr s 1,000i000
I '
Ut NQRIt+7'1O\OF OPERATIONS 1 LOCA71ONS I VEHIOL46 (ACORD 101,Aaalt,onal Romarlta Sollodulo,May he atta0hod If morn np000,R-roqulrod) " •��' - -"'
I
7
-
CLRT)FICA7ir HOLDER_ - �.-... .,_ _ •.
CANCELLATION
SHOULD ANY OF THE ABOVE;DESCRIBED POLICIES BL CANCELLED BEcFORI :
THE EXPIRATION DATE THEREOF, NOTICE WILL SE 11KIVIRED IN
At'.dORbANCR WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVH
ACORb 26(2014/01) The ACORD name and logo are registered mar z 1 s o ACORp D CORpORATiON. Ali rights reserved,
The Commonwealth of 1Vlassaehusetis
x Department oflndllstrlalAceldents
G
n I Congress Sheet,Suite 100
Boston,.MA 02114-2017
• ` '"°' www.rnass,go�/dza
Workers, Compensation Insura'z c'a Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FJLED I'W1T1I TliLU p)GI RMITTING AUTHORITy.
Ap�nt information ]?lease Print Le ihly
Name (Business/OrganizatiorAndividnal :
�
Address:—-A We b Pl a c=p PA R Z.n o
City/State/Zip: A� Phone,#•Are you an employer?Clrecic the appropriate box: .7
1. Iama employer with a� Typeofproject(required):
employees(full and/or
2.[�I am a sole proprietor or partnership and have no employees working for me in 7' ❑New construction
any capacity.[No workers'comp.insurance required.] $. ❑Remodeling
I am a homeowner doing all work myself.(No workers'comp•insurance required.)t 9. ❑Demolition
4.(]I am a homeowner and will be hiring contractors to eonduot all work on my property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees., 11•❑Electrical repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 12•❑Plumbing repairs or additions
These sub-contractors have employees and have worlcers'comp,insurance,, 13. Roof repairs
6J1 We are a corporation and its officers have exercised their right of'exemption per MGL c. 14. Other 5 Gaa✓r�j S y5'r� 5
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'bel~o howmg their workers'Compensation policy information.
h Homeowners who submit this affidavit indicating they are'doi��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 subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
X am an employer that is providing worlcers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name: m r a V e
Policy#or S elf-ins,Lie.
1 Expiration Date: n ti ti 2 n G
lob Sat®Addx-ass: l✓1�� I� Imo`�(/
Attach a copy of tlxe worlcers'eaznpeitsation policy declaration page(sliowi g the Policy number d expiration datV)�
]]allure to secure coverage as required under MOL 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 WORD 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.
X do hereby ce fy Wider the pains and pe ]ties o er•ur "tli at t/2e i'nfor�itiYtion prpyided'above is true and correct.
Signature-
Phone w.f',p J' :Y - .
9-
0
bate: Z I
fficial use only. Do not write in this area,to be completed by city or•town official•
City or Towvn: 1i'
' Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Cleric. 4.Electrical Inspector 5.Plumbing
6.Other
Contact person:
-------_____ Phone#: