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Home My WebLink AboutWiring Permit - Permits #12760-1 - 247 BRIDGES LANE 10/8/2015 Date.,...... .. �. ........ �NORrNgtioo `TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING 988ACHUg� � d `........ ��- ............................................... .l This certifies that ............... .... i has permission to perform i wiring in the building of, ........ . .. .. o North And over,Mass. c z .— .............................................. Lic.N L� Fee, - -��.................. .......:......... ......................ELECTRICAL INSPECTOR Check# ICJ� i i I �I i (;oae�owm�af�of�a�dae�wcsrfls official useronly Jt�tric� Permit No. 1 ,70 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/07j eave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in ac=dance with the Massacbnsetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT 11V INK OR TYPEALL BVFORMATION9 Date: City or Town of: N o rzA,-� N dc,v e..e� _. 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) awl t3rz d z ls�w Owner or Tenant Telephone Na w -toy a- Owner's Address Same as above , Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of B.uudmg Dwelling Utility Authorization No. Existing Service Amps ! Volts Overhead❑ Undgrd❑ No.of Meters New ee Amps / Volts . Overhead❑ Undgrd❑ No.of Meters Number of Feeders-and Ampacity Location and Nature of Proposed Electrical Work: q.S,l,A Com lidan of the follawbwtable mav be waived by the Lnewor of Wires. No.of CeIL� (Paddle)Fans r of To tal Na of Recessed Luminaires � Transformers KVA Na of Luminaire Outlets Na of Hot Tubs Generators KVA No.o me Na of Luminaires Swimming Pool A b dve ❑ -d, ❑ Ba Units Na of Receptacle Outlets Na of Oil Burners FIRE ALARMS No.of Zones Nm-0-fDet0Ct10Rand No.of Switches No.of Gas Burners iinitia' Devices. Na of Air Cond. Total Na No.of Ranges.' Tons of Alerting Devices eat p umber Tons KW o.of ontained No.of Waste Disposers Totals: petection/Alerting Devices ce/Area Heatin KW nni Other Na of Dishwashers 1 � S>� g Local❑ Connection ❑ No.of Dryers Heating Appliances KW- Na of or Equivalent (\� No.of ater KW Na a of of Data Wiring: �- Heaters; S' Na of Devices or uivalent Telecommumeattons u mg� No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E u' ent OTHER: . . Attach addfdonal detail if desbv4 or as required by the Inspector of Wires. Estimated Value of Electrical Work: $650•00 (When required by municipal policy) Work to Start Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless _ the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The .undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (SPM*') n is true and complete i.�' fy,.under-ge pains-and penalties of perjury,that Ae information on this app.hmWo FIRM NAME:Northeast Electrical Services INC. LIC.NO.:20782A Licensee: Daniel B.Kobus Sig o.JdC.NO.: (Ifapplicable,enter"exempt"in the license number line.) Bus.TeL No..` -966-7467 Address: 40 N.Main Street. P.O Box 361, Bellingham,MA 02019 Alt.Tel.Na: o. *Per M.G.L.c.147,s.57-61,security work requires Deparmaent of Public Safety"S"License: Lin.e c OWNER'S]NSURANCE WAIVER:.I am aware that the Licensee does not have the liability insurannce coverage normally required by law..By my signature below,I hereby waive this requirement. I am the(check one ❑owner ' ❑owner'sr ent Owner/Agent Telephone Na PERMIT FEE:$. Sigoafare 1 6N° The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia VVerkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeWbly Name(Business/Organization/Individual):Northeast Electrical Services Inc. Address:40 North Main Street, P.O. Box 361 City/State/Zip:Bellingham, MA 02019 Phone#:508-966-7467 X307 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 24 employees(full and/or part-time).* 7. []New construction In I am a sole proprietoror partnership and have no employees working for me in 8. 0 Remodeling any capacity.(No workers'comp.insurance required.) 3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. ❑Demolition 10(]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 LR]✓ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.- 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f 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 an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Paychex Insurance Agency, Inc. Policy#or Self-ins.Lic.#:NOWC535556 Expiration Date:07/08/2016 Job Site Address: 2042 '162%d e-s L.-Vtt3 e- _City/State/Zip: W�w ► `l Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration ate). 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde the pai enalties of perjury that the information provided above is true and correct Si ature: Date: \ 1 Phone#:508-966-7467 X307 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#:_ A ^arm CERTIFICATE OF LIABILITY INSURANCE 07/29/2015 DAT nYYY, /2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT pay�ex Insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. PHONE 150 SAWGRASS DRIVE 877-266-6850 FAX 585-389-7426 ROCHESTER,NY 14620 E-MAILADDRESS Certs@paychex.com INSURER($)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 NORTHEAST ELECTRICAL SERVICES INC. INSURER B: 40 N.MAIN ST BELLINGHAM,MA 02019 INSURER C: INSURER D. INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN t 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 TR TYPE OF INSURANCE NSDRL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDDlYYY1') (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ _ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS-MADEOOCCUR PREMISES( MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ I i POLICY =PROJECT=LOC PRODUCTS-COMP/OP AGG $ r—J S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED I—�SCHEDW cn BODILY INJURY $ AUTOS AU��T��OS (Per Person) HIRED AUTOS OAUTO-0SWNED BODILY INJURY $ P PROPERTY PROPERTY DAMAGE $ (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEO ' RETENTION$ $ WORKERS COMPENSATION AND X WC STATU- OTH- NOWC535556 07/08l2015 07/08/2016 EMPLOYERS'DABILTTY 00 E.L.EACH ACCIDENT $_ 1,000,000.00 ANY PROPRIETORlPARTNER(EXECUTIVE OPFICEWMEMBER EXCLUDED? Y E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 (Mandatory In NH) 1 N 1 N/A E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 Ii yn,desa+be under I DESI RIPTION OF OPERATIONS I LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILRY OF ANY KIND UPON THE COMPANY,rTS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE @1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD