HomeMy WebLinkAboutWiring Permit - Permits #12988-1 - 564 CHICKERING ROAD 12/28/2015 i
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j te OF NORTH ANDOVER o
/iPERMIT FOR WIRING
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This,Cell lac, that .,.. �_,.... .., ... .,., .��. ...............
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has permission to perfonn
wiring in the building
north Andover, ass,
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The Commoirwealth oaf" a.vvachmvtt i
mm" e rarr°twartertt qf hidusta"laal Acciele of
.. � ,ae,.�.,���." e�� State 1011 f l��ttt
Boston,AM 02114-2017
Ida tlw as s.govI
Workers'C°nrnpermsaation Insurance AlfidirviC Iinulcpers/C'ontu actors/E�ectr°cirmaas/Pitt hers.
'F0 BE FILED "M IIt P ItCt t l-I'ING att{IH t9t lY
.h Ihcsxnt Irtttarnaat,antr „�._.w..._._....w _ ._____., plesasa k'm rust 1 a abI
"di'rle "I3cirs/Claaraafiacauro��rmr� a ', C�... . r
Address: .su �� f � �I$ � _ _ f
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Phorrc
Are you a"caaployer? hca.k the appropriate N a Type of P r iij ecd(required)
1.0 1 am a er @e er ar aGda crap he e ew(fiA 8 and/or i&r,-teepee.
Y� t a... p �' pig � 7. ]htYewr a„esor,,da"rrctaa:>ra j
1 I run as sole proprietor or partnenaiip anrurd have aura erarpluayces wvwrtasag fOr°nx,gar d. � �It enio dehing
aunty;apacky"LNo wwerb:c�rs"comp insurance required,I
}. j Demolitiond. I am
a tdnn ctawvraex dadazg aahl w erk rray�self. Ran wvnrtcaw'earaaup,rraaurrance�rcrpurl�xed.l t
10 Building addition
4.0I am a homeowner and will be hiring cam haft s'do cat all Work,Oa MY PfripertY I will I I �^
ensure udraat0cunuacturs either lnmve��nrcp;r �" nnapev ernInsursnceyapsae",nic 1I,F]1-I etri aprep)<uirsnradditions G
pareaparactors with no einpWyLes.
B 2,El F Poaatrabing repairs or acte9itararu.=.;
5[3 1 wn wa ge mend emitractor said I Drava^hircd Sire suab ax ntr a•ta rs graced on die ata whedsheet. l 3, Roo f repaun"s
°llwsc sadm-oontrartaar,have ernpbyewei and have workets I urantp insir arm':
14 .�C"ltRter
b.Ej We are a ceapmaatrarn and Its officers have exer ised their rayta np a Xemptocxn pier 1W1CIl.,a,.
.
152,ss"d phi,and we have no enipIcy.ees.[No workers'rnrnpa uawsuoatasu¢,r quircal l
Array aiauaaS 6laa&clt a9 s lxrx td'1 raxast adsaa Cadl an thpe sectrsaaa Ietaww spauwwwlarg ttu a uwra6crrs"..°nnpn treaties aw gxrlaey urufarnvmaturxar u ,._ l
h kamei vruers�who submit this affidavit Indicating they are dap ng amid work and tdaeaa(tire otasadc cearwtr�acrov mruaust surbrnh a newa affidavit nu<daaPatinag sNr i
TC,n tr tors that che&tons fax n ast skla4i.d aan addiftial sMet showing th r utanniv(r6'th e sec-COI,.taaas a nki state vwpict Iucrr an not these,entities lave
employe If itic ab•contwasrs&rive er"ployces Ory neust providc dannr w orkers Comp.p 0lacy oukll)cr,
!art tin,errrdafeoie,r atraaa is praatate�tfrrp�:workers,e&ratreraauartaenee Irr,suriance.for racy»aarwaIMAjrrres, Below ds a/re ipolicy araadjob ashes
hi onnation.
u "._. 9c�at�n�atd..._
pratirat snort a( nrrrrpany Iwrantc°__ 5 r e t"" 31
y 8 ralta //orcld-rra,, I rc.
Job 1atB,zSit a Address
opy of the we �
leers"coorpensa atrr poHe°y ilea Iaration page(showing the pnplcy nu Ito her and expiration date).
Failure to secure coverage as required uneder'MGL c,152, 5 is as canninaal violation punishable by at lane up to$1,500,00
turd/tar one-year imprisonment,as Well tas Civil penalties in Ilmc f'rarjn of a STOP WORK ORDER and a0 fine cal ttp to$250,00 a
day against tire;violator.A,copy of tHs staternent may be forwarded to the Office of Investigations of the DIA for Inasarance
coverage verification.
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B efts hereby eertl ' udrafer tls� attire coast e tier ties as arras, t
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Offlciatl use only, dice most aerate in this aareatn to be cotrttpklesaf try,city aaa.taawn Offickri,
City Perm itft�icetuse k t
wn:
6,Boardaofflealth 2,BuildingDepartment 3.C.It frowvn t..'he.rk at.Electrical inspector 5r,Plumbing Inspector
Issuing Authority(circle,rune ......_ u....
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6.Other _._..._�_�_ � _ ...._._......_..,
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ACOPM& CERTIFICATE OF LIABILITY INSURANCE
4/ /'201
' It s t tt tt n t 'TAE CERnFICATE WOLDER. TMSXTEND OR ALTCR THE COVERAGE AFFORDED B'Y THE POLICIES
A CONTRACT E 0SSUING 0 '( ), AUTHORIZED
a TIO,N W DAMNED,sect to
m u tV apt wMV Mug BF uF mom use �a°m �of,this s� HMF ate�confer rights
Ebt.anEtE
Sullivan Insurance' Inc. Eu,E F1
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MAIL
87 Groveland Street34754
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INSURER E
ttnt.7MIA 01832W j
COVE CERTIFICATEtN � t� 202506t� �i�C�q NUMBER., j
"7Mk9 B TOE "Vi`NV^'"m"THAT THE '"4". k>6. R'S`IR�'S qAu• tRza"�I 'fi t^tM»7E6n� ^�d+a+ E �":E M aUED TO THE��@"�4J&�'P"D NAMED ABOVE FOR
�g^d�° 1�.�d',�"�PERIOD
"m C1N OF 1EMCONTRACT''C7 r0-niER DO TyM:NT M�111 01E°�i0"'ECI TO MPVmOCH TtffS
T EEt�T'GFtlC E ME ATED MAY C3T BE G w"xMNFF CIFMFBf 0M MAY PERTAIN, EC".00 TERM V0 p 7'WM t07 B m E G�"m"�W..drJF: DFSCRED HERFd JS SUBJECT TO ALL THE TERMS, %
7 a �.v ., �F ' PAJD CLAWS,
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, - EPbLL'P""';14 "i/ a/' i7 va ' �3/25/20IIL6 W fk E V�%fa�:y Or'�are w+�'uhu $ 5,000
PEonSCdM AL 9.ADV M.URY E 1,000,000 as
- W TgEF E G qM.&:Ov N E E 2,000,000
G3EKL A r4 REGA4 E U MM MhPM 4FE PER —
.For liEV" JECT Loc
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AUTOMOBILE LIABILU"T"Mf
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AUTOS AUTOS 566 TTT4kt EMaE
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EXCESS UAR CLAjMSMADE
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mm�MD FWD _
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OFFNCIERNEdq'MRF.NEX"4MDM"EIV M4FuE4EtE'.E 3/EE/2015 �3/AE/1tYE FV.& SEASF TA.EMMPr'�LOYER E �,,000,000
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DESCA F"'W(W OF OPFAATONS t u.M'sCAM N VE.IVEtEE(ACMD 10i,AddMOMI ftWWS
1,cd4edvka "my 4mwr wadwd E mmunr mce W mglwMw)
"Master, zlectrician,CER71FICATE HOLDER
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RMCO�WAt�4' FF't OFTHE, O�F�M7EC FFECM POLICIES�'CSO�C;E�'Ct�.ECE �
� ' nE, yH Fi"RA� DAB W� w E �E DMEU E E l
Town
t'� ~n: pot.er Murphy
7.,j EVTE Fra;0.0:&�OE:k` T
1 Tom. All tiger .
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as a aaas r. ar 4.id vial U s e Only
Permit No.
BOARD 1 PREVENTION REGULATIONS C�ccupararaµyawwctF'we C;lreciced
Re l/07 leave Mawr '
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APPLICATION PERFORM ELECTRICAL
All work to 1v performed in accordarwe with the Massachusetts EledricW Code(M C;),527 CMR 1100
City of 17own of. � To the i`t� ecltar rr�'l�'ires.•
By this application the undersiSwred vas r�cat'ica ark"�r�s zar Nita att�a�wwtt�rra�cr perform thet�c�rg N workc ri�cd below,
Location(Stivet&
Owner or Tenant
v
C4+i
Owner's Adatr s , t
Is this permit in r�anjurrawt building
permit? 1 es t o (Check Appropriate Box)
Purpose of uifdhi ( .- . , .. .� �_ _-_.. .w_ __. _ utility Authorization No.
Existin ;Service_ Amps ._ .., � 4 arttx Overhead t�� Und rd No.of Meters
y �5 _ Amps Molts OverheadEJ Und rd No.ot"Meters
Number of Feeders and Arttpae(ty` ,,,
Location and Nature of Proposed i —trical irrir
C"aarra afc taarrz o the ialdowkra table may he waived it i1h /my ctor o`N°d✓ores.
No.of c Luminaires s No»ofCeil usfr.fteldle) 'a t°w try sforwra rs VAa
lYo.of 1Luurinarire Outl No,of Hot Tubs Generate" KVA
No.ofLuauinaires Swimming Pool o. w .,rnex eney ..r a
ova wr
_� w_ ..._..... raid. d. tte tluits
No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No.of;Zones w
No,of Switches No.of Gas'Burners � oµ o ectron in .. �
luitiatin Devices
ota
_ ... __._.... tons > ,'e C,outa a
"otal leteaflertin evNc
o.o au es No.ofAwr f orral No.r
No.of VW to iyrspersarr�r t urra uru a orr o,a
ton/Alertin Devices
No.of'Dishwashers Space/Area Heating act f;ounew PP
ou 0tiwer
aril sterna. a
Ms.-
-No.of Dryers Heating Appliances y
No o vices or p uiva ut
o.o star , tr<o —�,,.�. ,..0.0 ..W.W.,�.,� fAatar"'�'irina
'neaten �i n� Ballasts
No.of Devices or E ulvalent
No.Hydromassa a Bathtubs No.o Motors Irood tip ecotuuaumeattous r n '
No.of Devices or u�a�at
Attach odditional detail ifdesired,or as required by the Inspector of tfi'res. l
Estimated Value of ElectricalWork: (When required ky municirmil ollc ,
"Ncorlc to Start: lwts��trrrns to be rccNwrr.-rt no permit fear the performance ol"elec,tric�ai work rasa worn.
cd in accordance with�!EC"Rule lq aw�wd upon completion.
INSURANCE COVERAGE: (Jnle s waived by tiro owner, i� y 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 suing office,
CREC (WE: INSURANCE 0 BOND [:] ty°iMER (Specify:)
I ee fyr,unl"er tke purls andpenedties ofperjury,that the t /orn don on this appHeadon it trive and compkie.
Z .
f aSi ratu t.�1C NCD, l
1�"fftM NAME:
. .� �.
/i a urleeeandr cater exr aB"in tBaa lacezxs^ i LIC�NO: .
w
(11 tl`I w e nraraahef brae.'' Bus. el Nro
Address:w a Alt.Tel.No
.-
*Per M G L.c taT s T 61 securityvotc requires 1 rarnl a c se S" icense. No.
t wa No
OWNER'S'[N CI"RANCWAIVER: t am aware that the Licensee does not l ve the liability insurance coverage normally
required by law. By my signature below,t herehy waive this retluiremewat, l am the(check one I owner owner's<r scant,
Owner/Agent, l
PERMIT FEE. '
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