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Home My WebLink AboutWiring Permit - Permits #12961 - 74 FOXHILL ROAD 12/4/2014 , ___ .~�~_ ` � ��,° _,_ - - - -..�- ~-- -�- ----�-_r-�� . Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services 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: '�; . 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) 7 eL,21 Owner or Tenant Telephone No. Owner's Address ,� 4 Is this permit in conjunction with a building permit? Yes R, No ❑ (Check Appropriate Box) Purpose of Building a, ,--s , Utility Authorization No. Existing Service Amps Volts Overhead ❑ 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: V16714-1 Al", Conrpletion'r of the.fbIlowing table ingy be waived by the Inspector qf*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 Above 0.of Emergency Lighting No.of Luminaires Swimming Pool gruel. El In- 0 Battery Units No.of Receptacle Outletsf No.of Oil Burners FIRE ALARMS INo. of Zones No. of Switches No.of Gas Burners No.of Detection and Initiating Devices .11W No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons I Heat Pump Number. .........t...............Tons KW No.of Self-Contained Totals: .........J No. of Waste DisposersDetection/Alerting Devices E] Municipal r-1 No.of Dishwashers Space/Area Heating KW Local Connection Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No. of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecom in un ications Wiring: No.of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail ij'desired, or as required by the Inspector of I'Vires. (When required by municipal policy.) Work to Start: e,,) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE 6k GE: 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 n BOND F] OTHER [j (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Z &A--- 762 LIC.NO.: Licensee: 7-'C7,) Signature LIC. NO.: (Ifapplicable, enter "exeinpt"in re lice Ti�e n nber line) Bus.Tel. No.: 2 4`/ Lf I Address: Alt.Tel.No.: �EZ(J' 1,',,S',,7? *Per M.G.L c. 147,s"57-61,security 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 0 owner [:1 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ,r C9 U� l ��•� OP ID: CB ,4coRO" CERTIFICATE OF LIABILITY INSURANCE DATMD/YYYY) �...� 12/2/O3/14 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 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 Phone:978-688-6921 CONTACT NAME: Macdonald&Pangione Insurance PHONE FAX P.O.Box 428 Fax:978-688-5350 A/c No Ext: vc No 104 Main Street E-MAIL ADDRESS: North Andover,MA 01845 PRODUCER CANTO-1 Michael Pangione CUSTOMER ID u: INSURERS AFFORDING COVERAGE NAIC# INSURED Canto Electric& INSURER A:Preferred Mutual Ins Co 15024 Thomas Canto INSURER B: 14 Sugar Pine Lane INSURERC: Methuen, MA01844 INSURER D INSURER E INSURERF: 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 ADDL SUB POLICY EFF POLICY EXP LIMITS LT R TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY CPP 0160 52 69 77 04/03/14 04/03/15 pREMISEs Ea occurrence $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS $ (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ _ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TIC LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under b SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Michael Pangione 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD GOIVIMOiVWEALTH OF MASSACHUSETTS BQA�ta of ELECTRICIANS ISSUES THE FOLLOWING LICENSE: AS A:.f2EG JOURNEXMAN ELECTRIC,I,A 1� TH MAS CiCANT0 i 14 SUCAR` PME ' LN Z W METHUEN NIA o1844-1858 .. 3083 .E 07/3<1/ 6 _ > 56 15 ® o The Commonwealth of Massachusetts Department of Xndustzrtr Accir�ents Qfitce of-Investigations 600 Washington Street Boston,MA 0.2111 -www mass govld'ia WQrkers' Compensation Insurance Affidavit:Builders/ContractoralBX Please Print or Jm b Meant InformatiOn usl (� ' , Name ness/Organizationftilividual): .A.d&-Css' '� ` ` `—� City/State/Zip: Phono#: Are you an employer?Cliecltthe appropriate box; Type of project(required): 1,C( x am a employer with________, 4. ❑ x am a general,contractor and 1 6, E]Now construction F gaployees(full and/or part-time).* have,hired the sub-contractor's 7 E]Remodeling am a sole proprietor or pai�a er� listed on the attached sheet. 2Those El woxlexs'c comp. S. Dealition ship and'have no employees working forma in any capacity, p insurance. 9. E[Duilding addition [No workers' comp.insurance 5. CJ We are a corporation and its l0,[]Electrical repairs or additions officers have exercisedtheir required.] rigbtofexemptianperlV.tGL ll.�D?lumbing,xepairsoradditions 3.[l Z am a homeowner doing all wort c 152,§1(4),and we have no 12,01 Roofxepairs myself.[No workers comp. employees,PTO workers' insurance required-]inll Other comp.insurance required.] 'Any applicant that checks box41 must also fill outtho section below showingtheir workers'compensationpolicy information. i-Homeowners who submit this affidavit indicatmgthey ft'ro doing all.worlc and then like outside contractors mustsubmit a new affidavit indicating such. TContractors that cheekthis box must attached an additional sheet showing the name of tho sub-contractors and their workers'comp,policy information. f am are emproyer that ispr'oviding worrfers'compensation insurance for my employees: Below is the policy andjoh site infonvation. f suxance Company lame:. policy#or Self ins.Lie. Expixation Date: lob Site address: City/State/Zip: A.ttaeh a copy of the workers'compensation.-Oolxcy declaration page(showing the policy number and expiration date). Failure to secure coverage as xequixed.under Section 25A.of MOL o,152 can lead to the imposition of criminal penalties of a figs up to secure co and/or s re quire-year imprisoinn ent,as well as civil:penalties in the form of a STOP-WORK ORDER,and a fine ofup to$250.00 a day against the violator. Be advised that a copy of this statement may bo foiwarded to the Office-of 7uyestigations oftho M&for insurance coverage vexifloation, X cro Hereby eerto uatter tree panes and pegat jes ofperpuy that the informadon proviclecl above is true and correct Date: w .L O11C3'°'i » Official use only. Do not write in this area,to be completed by city or tolm offZaial, City or'�'awxi; D'ermit/License# ZssuingA.uthorlty(circle(me): 1.Board of Health, 2.Building Department 3.City/Taw>a Clark4.EZectricaXXnspector 5.Plumbing Inspector 6.Other u Contact Person' 'hone#: