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Home My WebLink AboutWiring Permit - Permits #13109-1 - 24 DEER MEADOW ROAD 2/12/2016 conunowea&o/*"."th Official Use Only Apartment 013i.S.,.,,i,. Permit No. 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 (PLEASEC PRflVT DV INK OR TYPE ALL INFORMATION) Date:— z,/;Y IltyorTownot /��,,r/,4 4)e1,1X,,,�e,1,- To the Inspecto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) e xe Owner or Tenant V011/5, SIA,1011*1111�41-111 Telephone No. 'i- Owner's Address 64, , Is this permit in conjunction with a building permit? Yes [Sj' No E] (Check Appropriate Box) Purpose of Building 5 As", Utility Authorization No. Existing Service Amps J "10 Volts Overhead❑ Undgrd No.of Meters New Service Amps Volts Overhead❑ UndgrdF1 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion pf the allowin table mg be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminalre Outlets No.of Hot Tubs Generators K-VA No.of Luminaires Swimming Pool Above 0-olEmerge- CYL11gtitffig— grud. El R�tte Zq:_9 _M Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.-oMetecMin and 2., Initiating Devices No.of Ranges Na.of Air T 0- Cond. Tons (0 No.of Alerting Devices No.of Waste Disposers eat mp um er Tons o.of Self-Coit—ained -- Totalk I Detection/AlertimDevices No.of Dishwashers Space/Area Heating KW I.,ocal, uni'Lclp!u n Other Connection No.of Dryers Heating Appliances unty ystems: KW ec 0.0 ater No.of DevicelslorE uiv No.of _F&W alent Heaters KW No.of Data Wiring; H signs Ballasts No.of Devices or Equivalent Telecommun capons No.Hydromassage Bathtubs No.of Motors Total lip lecommunica ons Ang: No.of Devices or Equivalent (1.7 OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of E!Fctrical Work: 1`2Z ele,0 (When required by municipal policy-) Work to Start- Z � Inspec [—is to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CU AZ' GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee Provides PrOOfof 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 pen-nit issuing office. CHECK ONE: INSURANCE P�, BOND F] OTHER El (specify:) I certify,under the pains land penalties of perjury,that the information on this rpucation is true and complete FIRM NAME: / 1k, 7 9,-4",-le; vo LIC.NO.: Licensee: Signature or exem af applicable 1 11 1 —/,C LIC.NO.- Ipt m the license number line.) c, Address: Bus.Tel.No.• 2 6 *Per M.G.L.c. 147,s.57-61,security work Alt Tel.No.: requires Department of Public Safety"S"License: OWNER'S INSURANCE WAIVER: I an,aware that Lic.No. the Licensee does not have the liability insurance cove- required by law. BY MY Signature below,I hereby waive this require rage normally Owner/Agent requirement, I am the(check Downer El o Signature Telephone No. pE r :S _ _ �4�,.4 � t '�, =,I ,� � .',. \� . .., . 1'' �� ., , 4� �1\ t .. 1 (`V�` V .___. I � � I Date.��\.Q... .�..�. 4 NORTH r ,�'•�,;��oo TOWN OF NORTH ANDOVER F 0 L t G p PERMIT FOR WIRIN 88�CHU'3� Q This certifies that :. ... . ..�� has permission to perform '.. ....`i....... ram® 0 Vq �I........ ?, .�`°..�.......................................................... wiring in the building of....�,:....�......:... North Andover,Mass. at , .... Lic.No. ' .��....�............................ .. Fee � a••• ELECTRICAL INSPECTOR i Check Check# � f ', DATE( /DD/YYYY) A ® MM CERTIFICATE OF LIABILITY INSURANCE 12/3/15 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(es) 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 endorsefnent(s). PRODUCER CONTACT NAME: W. Gochis Insurance Agency Inc PHONE (78l) 272-8306 FAX N (781) 272-1362 113 Cambridge Street E-MAIL Burlington, MA 01803 ADDRESS: gochisl@verizon.net INSURE S AFFORDING COVERAGE NAIC# INSURER A:Commerce Ins. Co. INSURED --- — - _ INSURERB: Christian Theriault INSURERC: dba Theriault Electric INSURERD: 168 B St. INSURERE: Dracut, MA 01826 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I R WVD POLICY NUMBER M/DD/Y MMMD/YYYY LIMITS A GENERAL LIABILITY BDNPNV 2/10/15 2/10/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGETORENT ED E ISES occurrence) $ 100,000 CLAIMS-MADE [A]OCCUR ME EXP(Arryone person) $ 5 000 PERSO NA L&ADV I NJU RY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-00 MP/OP AGG $ 2,000,000 X POLICY P O- LOC $ AUTOMOBILE LIABILITY CafcidentSINGLELIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS eraccidenl UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN IORY11AAlP ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if mores pace 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. 120 Main St. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE/' T ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: a�o CERTIFICATE OF LIABILITY INSURANCE DATE 121071DD/YYYY) 12/O7/2015 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 03181 -001 NAME: W Gochis Insurance Agency Inc a/CONNo.Ut: (781)272-8306 A/C.No.: (781)272-1362 113 Cambridge Street EMAIL Burlington,MA 01803 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED INSURER 8: Christian Theriault INSURER C: 168 B Street Dracut, MA 01826 INSURERD: INSURER E: 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. I�TR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDNYY MM/DDmYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGETO MISES RENTED $ PRE Ea occurrence CLAIMS-MADE ❑OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ OLICY ROT OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION $ T $ 'rNS'yd�gRbi��p�Ro��ET€�ptsR�/C�ga'R�RNgEf�4/�X X TORY LIAMITS OER OFFICER/MEMBER EXCLUDED?ECUTIVE Y/N E.L.EACH ACCIDENT $ 600,000.00 A ❑Y N/A VWC-100-6016080-2015A 8/31/2015 8/31/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 600,000.00 DS�RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The workers compensation policy does not provide coverage for Christian Theriault CERTIFICATE HOLDER CANCELLATION Town of North Andover 120 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ',y ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD SCE��'�GETM_ _-•-'`r--•— - •, LOI' MONWEAL.TH OF MASSACHUSETT- - ROARS OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE, AS- A- REG JOURNEYMAN .ELECTRICIA CHRtSTIAN M THERIAULT z r'• kid 168 B ST DRACUT htA 01826-2154 52084- E 07/31/6 64330 v {aioaaayao=— —m.• _. e.. .. The Commoniveidth of Missuchusetts Depat-intent of Industrial Accidents Office cif Investigations - 600 Washington Street Boston, MA 02111 )VIvivanass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please pl-int Name (BLisiiiess/orgaiiizatioiiiin(liN,iciti(ii):—(, 74, Address: /6 'V e", ,e hone #: City/State/Zip:__,,�� ( � Are you all employer? Check the appropriate box: Type of project (required): 1 am a employer with--- 4. F-] I ani a general contractor and 1 6. E]New construction employees (full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.t 10.F� Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ 1 am a homeowner doing all work officers have exercised their 11.FJ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12,❑ Roof repairs insurance required.] c. 152, §1(4),and we have no 13.F Other employees, [No workers' conip, insurance required.] *Any applicant that checks box 41 must also fill out the Section below Showing their workers'convensation policy information t I-Ionicowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. I -oi,not those entities have lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ain an employer that is providing ivorkers'conilmnsation insurance for iny employees. Below is the policy and job site information. Insurance Company Name:_------ Policy 4 or Self ins. Lic, #: Expiration Date:- Job Site Address: City/State/Zip:___ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certyryl.,1111(l Ai his,andpenalfiekafpeijuij,that the information provi(led above is true and correct. "r, lepa Date: Si nature: 6) Phone#: Official use only. Do not write in this area, to be completed by city at,tolvil official City or Town: Permit/License 1,st,in,Authority'circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone