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HomeMy WebLinkAboutWiring Permit - Permits #12847 - 10/28/2014 Date.........�...........bd".¢..6.� .......... I i RT OWN OF NORTH ANDOVER QF� TOWN Q"p PERMIT FOR WIRING a ACNU5 Y This certifies that .... _ . haspenssion to perform. C �` dA d wiring in the building of .. � �...........` p North Andover,Mass. at ...... cm fH V'y. .....:. . ... .E.. L . ...:..... RCALINSPECTOLic.No. CT R Check# --=— — I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. vr] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10 — ze) — /4 City or Town of: NORTH ANDOVER 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) P vo -r Owner or Tenant Telephone No. Owner's Address FAA L Q-,J',-r f 0 1 4-1-\P V 1-0---L Is this permit in conjunction with t a build I ing permit? Yes F] No �4, (Check Appropriate]Box) Purpose of Building Utility Authorization No. Existing Service 'ZOO Amps 1 P ZP i Volts Overhead n Undgrd Ir No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: i Nei tWSTW-C-> I( te-,X L k-4"i S 902, io 60 Colpletion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above Ei In- 1:1 N—o.oJTjEm--erg---e-nc-yLjg ting grnd. grild. Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo, 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 Number jTons J.KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ElMunid'�Pl n 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 lNo,of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent 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: to-Z,0 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 cover ism force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSUIRANCE BONDE] OTBERE] (Specify:) Icerloy', under the pains and penalties ofpetywy,that the information on this application is tine Hurl comp lete. FIRM NAME: %Ut7-' le(cr 17 17 IA LIC.NO.: I LA Licensee: NV�&j N-6 Signature _ LTC.NO.: (If applicable,enter "e'p,Mpt"in the licensfpuniber e. Bus.Tel.No.: ......... t V k We2 Address: �Z ter Alt.Tel.No.: *Per M.G.L c. 147,s.57-d1,secutity work requires Department of Public Safety"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)EI owner [I owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of li2'assachusetts -' Department o,f�n�'�cst�zr�rAcczclents Office of Inves9gallons 600 Washington Street .Boston,MA 02111 vww.rnass.govIdla Workexs' Compensation Insurance davit:Builders/Contractors/PlectrxciansfPlihnlbers A,.ppReant Information Please Prim Legibly •Name(Business/Organization/lndzvidual): M —, L)JZ 'Address: (Z City/State/Zip: VJ, A2P p,,--ems " 0" Phone#: q"fig' -2 0 Ax•e yo employer?Check the appropriate box: Type of project(required): 1. I am a employer with_�� 4. ❑I am a general contractor and I 6. ❑New construction employees(fall and/or part time)* have liked,the sub-contractors 2.[] I am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and`have no.employees These sub-contractors have 8. [(Demolition worldng for me in any capacity. workers'comp.insurance. g, E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10. lectdcalrepairs or additions required.] officers have exercised.their 3.❑ I am a hoin.eowner doing all work right of exemption per MGL ME]Plumbingxepairs or additions myself.[No workers' comp. c.152,§1(4),a-adwe have no 12,Q Roofrepairs insumucerequired.]t employees.[No workers' ME]Other comp,insurance xequired.] 'Any applicantthat checks box#1 must also fill out the section bel6w showingtheir workers'compensation policy information. Homeowners who submitihis affidavit indicating they sro doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that ispr oviding workers'compensation insurance for my employees Below is the poliey and job site infarmation. Insurance Company Name: ��� t rJ�:a z,� G) .Policy 4 or Sel£in.s.Lzc.ff �y 7 Expiration.Date: . s Job Site Address S f�A S k,�p P'z 0Ti-i T City/State/Zip: (V A!-�py ea CJ Attach a copy of the workers'compensation-p olley declaration page(showing the policy number and expiration date). .Failure to secure ooverage•as regyh:cduuder Section 25.A.ofMGL o.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 DU for insurance coverage verification. X do Xaereb e t er'tliep'ains and hies 'ury that information pr oviclecl above is true and eo)rreet. Signature: Data: ® / Phone 4: .- Official use ortly. Do not write in this area,to be completer)by city or town official; City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityMown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Pers on: Phone 0: OP ID:PM CERTIFICATE OF LIABILITY INSURANCE OATi fYYYY) 021051105/14 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 pollcy(les) 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 413-594-59Bfpc CONT AME;CT Patricia Mahone PHILLIPS INSURANCE AGENCY INC HONE 97 CENTER STREET 413-592-849 413-694-68ti4 ac No:413-692-8498 CHICOPEE,MA 01013 MAIL att hllll slnsurance.com PHILLIPS INSURANCE AGENCY INC ROD CER USTOMER IO NNAIUR-1 INSURERS AFFORDING COVERAGE NAIC 0 INSURED Maluri Electrical Corporation INSURERA:Peerless Insurance Com pany 24198 Malcom Constructlon Services INSURER B:Oh 10 Casualty 85 Flagship Drive Unit J North Andover,MA 01845 INSURER C: INSURER D: INSURER E: [INSURE 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. I 9R TYPE OF INSURANCE POLICY FF POLICY E P LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1100010 A X COMMERCIAL GENERAL LIABILITY CBP8931209 02/09/14 02109/15 pREMISEs Ea otcurronMj co $ _ _ 100,00 eCLAIMS•MADE a000UR MEDEXP(Any one person $ 10,00 X XCU[net FORM CGO01-1001 PERSONAL&ADV INJURY $ 1,000,00 X BlanketContraCtu GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,00 POLICY X JFCT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) A ANY AUTO BA8837509 02109/14 02/09/15 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS BABB94620 02/09/14 02/09/15 PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNEDAUTOS $ $ X UMBRELLA LIAS X_ OCCUR EACH OCCURRENCE $ 10,000,00 EXCESSLIAB FCLAMS-MADE AGGREGATE $ 10,000,00 � CU8834209 a E0064702614 02/09/14 02/09/15 - DEDUCTIBLE $ X RETENTION 110,000 $ WORKERS COMPENSATION X WCSTA U- OT AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETORIPARTNERIEXECUTIVE Y!N WC8835808 02/09/14 02/09/'15 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? F NIA C8036908 CT 13 3A STATE (Mandatory In NH) 02109/14 02109/15 E.L.DISEASE-EA EMPLOYE $ 11000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 A Equipmen Floater I ICBP8831209 07J09114 0 0 115 Leased Eq 120,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Att itch ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER C TO PROM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To Provide Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE nrL - 01988-2009 ACORD CORPORATION. All rights reserved. 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