HomeMy WebLinkAboutWiring Permit - Permits #12805-01 - 565 CHICKERING ROAD 10/26/2015 Date
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TOWN OF
NORTH ANDOVER
PERMIT" FORWIRING i/
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l APPLICATION FOR � PERFORM ELECTRIC _W_._O...RAll w rc¢a p o /ra sed in tic a ;e
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city t # JI u
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13y this tIc ttion the ur
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t cCo ?fGC it°c tatcr( o Ic xf rrr 91c electrical"ork described ibed below.kocrtior (Strectc Ntrnbrr�7 � 4; r:s
C)rvracs Or Tenant
Owner's Address _
Is this,pe:t�ralit ill e<naynrae,i4ara wsfix at building pernitt", `1 eS . _.._,.._...o
No
ldJ (C,l'sr.c'rlc.hlrpreslx°iasta FSax)
� k'nrpnsc cr'#"F3uale3in#; _.__._��
_.___ C)fility Autimricartion No,
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Existing,Serr*c..___�,.. Arn ps _w...._.._ -._._VrBts Crerlecff 11 lxc e1Nen � y
__o, rl'M_e_t.e_r s °
Amps .. ,_-. . yfaxl'ts ()verhea d ww p
Number ofI{eeder s and Ampacity �__1 [)ssx3t r°d�..e No,Of'Aleter"
I cre lfsexsx and Nature of k''z-Wl7 scxf Elegit¢sr,t15Vc r9r
4
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f errravlc(rena ' LE Jotl�rw s !/c rrteaa be wens c e!br,the bz r cctor erf P�T�u es.
No (If Recessed I uxnsrz xis-en _ Na t.ri
�Nc ufl(cal cusp (I addle)Farm I at tl_ _ ._ k x cra t t zne r,s
Na.(r#I vminasre Utrtl is
1C�1A
No,Of"Hof lzsh, ( cn a xtors KVA
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1dts.of urrtinarir°es Swimming,C marl DO ��� o"arii�s*e-r errciy%lii�rxirri4
�rerve ..�
_._,_- kl xtte;a L 3lrtrfs
Ne7,afklee.epfacle Cutlets _ .._-._._.
Nra girt C)iP ISsrrsters11
k UU],Al ARMS No,cif Zerr'tesNo.of Swit"ches
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_No Of(3as I3ta'rners �vo.eal lJete.crion and 7
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Isaafo ttrrr�:T3esvices No.of Ranges Nr n6 d ts°( asrrCl �ertal
Lw �Ncx of Alerting ting D vices L'
Na.of SSrasEeDi Disposers ller tutmpb kVrxsralxer Tnrxs ]flnr Vo of 4el# �<>fit -line
��_ _..__. klete^etstzta/Alerfrttti,ie.es
Nn,e Dryers_. 111 aura A.'r]lest rrv�ksVv C tanste
_ are/,use Icr tl[ J4isar
C)fF�Nr
9S rava*srer:; r�
- ____._.._. .... nccfsrart
l lalrltataccs 1:4Vr Cetrsrrry ysl�etns
_ Sl'2US _ Ballasts..,.._. __.- Daty"crling ie;es
Heaters
eat _., err I caessi tle,nE �.
o.cri trer
?es €rof __..._ __.. Naa girt Yyevarra or I"a tsra alent )
kke rta rs
Ir lVo rrJ 1. 1 f
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No.Ily dromaassagc Bnttstufsv Nn o l4�rr1_es s ka leclrartrxxsrrts afaosr5°�4 tszng
7Tota1 Ilt files.€al l)e. cafJ or I'f, trivia
C)'I'E ER: — ___
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q e f tlezcOd u r lrttaarc:/r(c
T Prssl f cia sh'd Or er r e guirz c1 bar the)ix7ae cloy crf P7�fr�es j
:wtivtatcd Valuea>tlleotra"ca} 4Vrr"lc: ti t (a7 Iresn r yttraecl by araunre;rlxvrl lrolacy
Work to Start _ > ���--
lnspe,ctacysa< trr lar r qut trd in%Icc;crdanct with MF C Rule 10 and ulmn cornpletican, 1 ES'C);RIVC"k�,CEJrCfl2la C#+ Unless waived l7y the cvarrca,nca},>a,rsnil f r klre:larrfatn'ranae ca#ule,ctrie;¢a!w✓e rtc zraay i;asxae;aamlcss C
fhr Iic,en t •provides proof`of It atrility ttr=arrcr rrx;Ivdiorp ¢;omple te,cl operafion"coverage,or at� ar,rbstartfipal e:c uivaferat. The r�
undersigned c`crftrr€s that such rOverape t rxx fixra e astd ita c xftn:,rstr ptot>fnf rnae to tlsc pc,rratxf listtill eaff�iCG.
CFdLC;IS C7JT. .TES UkAl7Ck
1lOd�iCa { CYJS�JJ la �vt1 I Bert y,toad<r tls.e p afns and pxelzoltia„r fxr;rpa r-d,,tluaf alca[rariar'raarrtrort ore fttts°a,rlaCrrc taorr t fiur arzrC ee�rtzpT.etc. r
IrIRMNA-Affi: DC LLC I)k-3A f?i))
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Lzccsascs k'a���� CY. d,r E' •�-_ r ,,,_ ___-__.
Addr(Yaess:
,ear( rrth lrrc c raur cr lraar d rr f$trrr i .....
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C 1 c. l4" s 5J G1 <scttrii rnrcar) trrtarn N ,)vs Ytrat 4:7f' 1117iaG ai rtt C`1 e%'i IC`C't'.Y%e,..
OWNER'S IN�SC.C[ AN(k W J"t EJZ J am awire,that the u accnsc.t duos iinorwrc:the(aarbrlrty artsur�rrc�r crve a-age �rrrra(lyc�
required by la'vv. BY rtry strrnature bolo ,1 hcsreby WRi~tt this a t�qui'rex"Ir,srat. �B:aarn f6r ,.Iaec;le'carte"Clrwrrc,r°!Agent: ( )[ o'svnor ED ownct's aeetr'f, s
Sigrsai.rrc __...._.__._. Idep1aoneNo. E'�" �Et1T'.ITll y if
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1 C;�xrr r as:s 5'/r rxr t,a5"uite 100
_ rzr;�K�an /pM rl2 a r�t..20_1.7
mvW.r 1a&V.gOv✓rlier
Wor-lwrs'Coin perlsaiiorr Insurance Affidavits ;lnilclecs/(;rrrrtr netrarsl�;iratt:ricisttrsfP[trn7B�er s.
TO BE FILED 11 I H"f"FIIs.PECtCvftTTING AC.1°f'HOWT V,
Arindicantlnformmtiora _. Please Print fle_itrly
EtTT7G'(t3usnrnt;s/C)rtani�ationlin7diviclttral}: rc.._.....~�; .„.�../'ta,:µ't_ "". C„„1C';,'.,,,,w.p'�"
Address:
f _ r
t city/State/Li}): .w � }'41
0
1
at it.:
Are you an employer.Check the appropriate box: Type of project(required):
uired
I.[ ,:lan'raemployerwvith ,fkk1' ernployces(full aaed/orpart-finw).* 7 New construction
2.[]1 am a sole proprietor or partnership and have no erriployues working rbr ine in 8, Reinodeling
any capacity.[No workers cornp.fnsur rice regrrfrcd.,l
f
9. []Uenaotitiata h
3.[J l am a homeowner doing;all work myself:[hdo workers comp.insurrmc:e ru¢lrrired.]''
101 Building addition
4, f am a laarrreowner rend will be hiring corrtractcrrs to condrrcf r:rll wvurta am my property. I wi11 _
ensure that all contractors either have workers'compensation insurance or are sole I I.[.—j E lectrical repairs or additions
proprietors with 110 employees. 12. Plurnbing repairs or additions
5.E]f am a general cantractorarrti fhave hired the sub-contractors listed on the attached sheet. p 3.[""I[hoof report's
These sub-connaefors have employee rndhave wvorkers camp insrorance.+ t t
G.F]we are a corporation and its officers have exercised then ni to of exemption emption per M01,c
14. Other .A_t L ,
ISM $1(4) and we have no employees.[No worker comp.insnr uace reytrired J �t
m i
*Any applicant that cheeks box III roust also flit out the section below showing their workers'cornpensation policy information.
t 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 additionad hest showing,lire n arne of fhe sub-contractors and state whether or not those entities have
employees. Ifthe sub-contractors have employcrr,they mu t provide fhcir work ers cornp policy nurrrber.
r
I ani an e np)toyer that 1s providing lvorlrers'compensation insurance far my employees, Belton'is the polic•p an(Jab site
ftZfarl'Y'H'rtat7F7.
l Insurance Coznl7any
policyorSelf ins laic.tl:._ � a E;x[airtati�r�rf Date:
...._ t,
..
Job Site Address: ?f ret _s .,. City/State(lipr: v4 ._ rka < t
Attach a copy of the workers'cornpensatiora policy cleclear dMaon page(s(zaoaanf the policy::.t.rat cr sand a xpfrd,tiora date),~
Failure to scc:ure coverage as required under MOL c_ 152 §25A,is a ct ffnhial violation p)urnshtalrte by a fine up to$1,:500.00
and/or one-year iniprisonnaent,as%yell as civil penalties in the fierna of a STOP WORK ORDER and al fine o'f up to$250.O0 a
day against the violator,A copy of this statement indy be'Forwarded to the;Office of investigations ofthe O'IA for insurance
coverage veriEieation.
I eta leer"ebry certify urztler deco pains and penalties ofpeijrr y that Me inforinallon provNerb above is tare and correct. �
SnGfttzre_ �rw uw, .a. f7 a,ko .. ( ...._ ___- _ --- l.._, .,.. h
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Phone It:
.�C7fftclat a.se only. lea teat rrrrife trz ilzrs,area„to fits cr>tnpalc.tert rxy cltjr c✓r tevavrz crfj`r€•iaC.
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City orTown: Per'rrrit/License tl
issuing Authority(circle one,)-
1.Hoard of 1lealtlx 2.Building Dep)tartnimit 3.City/Town Clerk 4.Mec.trical Inspector S.Plunking lnsp)eetoi-
r
6.Other,---
Contact Person: Phollefl: ..----__ —
_� _.._. ... _.__..._..___.__.................__......._.._.___.__,.
_____. .._.M....._._.._..__...__.._......._......_._....._..._......._._._.._._______.____.
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CERTIFICATE OF LIABILITY INSURANCE n1C 4f1t0115rr/xvv y l
�1�C."kCJ/d"L�•� 1
._ v
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS j
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA-TIVELY AMEND EoX'I`END OR ALTER THE COVERAGE AFFORDED BY I-HE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
RE
REPRESENTATIVE OR PRODUCER,AND THE.CERTIFICATE HOLDER, lj
IMPORTANT: It the certificate,holder Is an ADDITIONAL.INSURED the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the tarns and conditions of the policy,certain policies may require mi undo,ernent, A statement on this ceir dicatr does not confer rights to the
certificate Haider in lieu of such endorsement(s). _ _u..._
PRODUCER CON GACT �Y
Mardh
AX
60 (/w,frir¢ C,or wwate I'kw fkme YX GA4:.r
PHONE
>uarhm,F d
ABirc('It',�NID� I W FVo.f.atGd, _ _ I J:n/o Nul.L 431d.S ao MAIL.
INSURED Ar n CAIrlrnRoaKElvr r r e`tmpa ry CrYVLRAkGk: 22",ii AlC X
lord Tte,Cc,rBvfrrr Ir;kr€.oGn
(148119 31 AI)T f AVV 15 15 atkultrf: F" Y
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1E t'liro-tr�rt l)rivGr oru�,lanPot, Af,I.Fire Unde fwrdnrs(Co 47a)
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COVERAGES CERTIFICATE Nl6fVHRR AIL�003446293,04 REVISION.....VIBEFf
7HIS IS I0 CIERDI•Y THAT THE POLICIES OF INSURANCE LiS[E D BELOWt!HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 6nR THE POLICY ICY F CRIOD
INDICATED. W)TWfItiS'TANDINdG ANY REQUIREMENT 'TERM OR CONDITION OF ANY C7ONTRAC,t Ck 01HER DOC:',LIMENT WITE1 Ldk sf-,rc"i To VVEI cii'ifiis �!
Cf PrIFICAIT MAY BF ISSO!'D OR MAY PEWAIN lffl INSURANCE AFFORDED BY THE POLICIES S DESCRIBED HEREIN 13 SUBJECI FO ALL IIIE iFRMi, I
tN EX'.Ct USK)NS AND CONUH IONS O k;UC.t1 Pt 71 IUIE I IIMI I.r r;MuWIN MAY HAVI Pil I N I EDL1C,f rl H'd r AB€'MAIMS
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CERTIFICATE HOLDER PANE I fl I ATION
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a'EIf 1ND L.ra ANY OF "FIE`.ABOVE 6'16 (`.RI6:i Pf>I'GdN YCIFc,fIB....%;AHlC;r•4 t FI.Y[3EPG".iRT;
AIIrI Elcdgiu0lo¢Hector THE EXPI1AAl"VIJN DA"rE; X HhREOF, NOTICE WILL Sr D LIVERE0 IN
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