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Home My WebLink AboutWire Permit - Permits #13073 - 240 CHARLES STREET 1/20/2015\\sm,IFHIM An Date . . ..,..:.. ................. MINI Up 1gm 11 \ oVER �k RTjj am TH AND \\ggggp OF NOR 0* TOW +� # ® 'OR INNWIRING \SE �Am IFS MI �` \ 'M gm _� ®�® 17 :•,. 10 1110 00 r HIM :... �S \ \: .. This certifies that ............. �� F... ate... . �M erf �, ems..... . \ knumm \\ haserm sn t p ; wiring in the building o .:.....,. .9 � .. .................. � North Andover, ass. \ ME 01, ............... EVER .... r O \ ....... OINK \\ R ....... &'ARM ' 0. N$ URICAL c ELFC� .EFee. g = MEN' \\ Check ` \ �l \`MINN � RN o Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (Please add gig codes & electrician's cell#; [Rev. .1/071 (leave blank) contract# & bid permit#if apg1tqqPL2d APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code( R 12.00 (PLEASE I-WINTIN INK O INFORMATION)TYPE AL L IN OR MA TION) Date: /71-15 7J k 5 City or Town of: N 9A) )J-eA To the—InspictorQf Wires: By this application the undersigned gives notice of his or her intention to`perfortu the electrical work described below. Location(Street&Number) aoArvt- 6reAA (4draelcCAm Owner or Tenant b6JU Telephone No No.. V7� F_a4 12, Owner's Address �All ✓CA , q9Z MLI-- Is this permit in conjunction with a building permit? Yes Fj No er (Check Appropriate Box) Purpose of Building_J LMX.WA Q Utility Authorization No. Existing Set-vice 1,/J Amps 1A2_12"l-Volts Overhead UndgrdO No. of Meters New Service Amps f Volts OverheadF] UndgrdF_1 No. of Meters Number of Feeders and Ampacity # Location and Nature of Proposed Electrical Work: _44_ tkw Z - J&9VQ ,-W VAtl Gam"N-S t*v/) Completion of'the follow ing table may be waived by the Inspector of 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 No.of Luminaires Swimming Pool-Aboll-e 0 1 ❑ Y(. of Emergency Lighting grnd. 9rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones_ No.of Switches No.of Gas Burners No.of Detection and Total Initiating Devices Tons No.of Ranges No. of Air Cond. No. of Alerting Devices Heat Pump Number Tons -TRW_1No_.of Self-Contained No.of Waste Disposers Totals: IDetection/Alerting Devices municipal F1 Other No.of Dishwashers Space/Area Heating KW Local EJ Connection Security Systems:* No.of Dryers Heating Appliances KW 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 Telecommunications Wiring: No.of Devices or EquivNent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Ele rival Work: 1000 (When required by municipal policy.) "ec r' Work to Start: 15 Inspections to be requested in accordance with MEC Rule 10,and upon completion. C4INSURANCE C VE AGE: Unless waived by the owner,no pen-nit 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 F] BOND 0 OTHER [:1 (Specify:) I certify,under the pains and penalties perjury,ry, that the infortnation on this application is trite and complete. FIRM NAME: EU)14,; 6:rC_Cfi1-46 co -D,), LIC. NO.: #7 LIC.NO.:4.5 Licensee: Sigmature (If applicable, enar- "exempt"in the license number line.) Bus.Tel. No. Address: Alt.Tel.No.: *Security System Contractor License required for this work; if applicable,enter the license number here: 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)F1 owner 0 owner's agent. Owner/Agent 7U-1 Signature Telephone No. PERMIT FEE; $ )',*22' '7 The Commonwealth of Massachusetts ° Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-201 7 *`y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): G�+J/f7t7 Address: C) ` L7 City/State/Zip: f /� IVH Q hone #: 60J `!f&_3 9 ks Are you an employer? Check the appropriate box: Type of project(required): 1.� 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or gart-time). * have hired the sub-contractors 6 ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have S ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance camp. insurance.t ❑ Building addition required.] 5. -We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 131-1 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation 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. TContractors 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: (}tce I Policy#or Self-ins. Lic. #:� Gliz. Ce. �ry¢ . Expiration Date: 6 0/4-5 Job Site Address: '"`" X- . 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 MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7 do hereby certi underthepoitts°,° d enalties o f erjur t/xat the in ormation provided above is true and correct. Si Tnature: 9LL � Date: /✓ — ,/) p» Phone#: �%�' ✓_ 3 � 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: :.t'0MMONW k It .OP MAS��k�HI�JS TT "NIP C1 ANC.. :1+41LG7R1CA:l CO CNC .WON Pi I L�1 P�1 '4 K 03037�1 .. .. VJ tJi1Ut E1WW TH fy M`-' ks ► S NS jV Ol :r y a ° . ss �- paaaN <1 1=1 F f L .. k l 103037 1.4 ACAC)R" DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 1/13/2015 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 CONTACT Susan Gilman NAME: THE ROWLEY AGENCY INC. PHONE (603)224-2562 FAX e.(6n3)224-s012 139 Loudon Road EMAILADDRESS:sgilman@rowleyagency.com P.O. Box 511 INSURERS AFFORDING COVERAGE NAIC# Concord NH 03302-0511 INSURERA:Travelers Indezrinity Co of Amer 001111 INSURED INSURERB:Travelers Indemnity CO 25658 Ewing Electrical Co. , Inc. INSURERC:Travelers Prop Cas Co of Amer PO Box 370 INSURERD:Travelers Indemnit CO Of CT 001110 INSURER E: _ Deerfield NH 03037-0370 INSURERF: COVERAGES CERTIFICATE NUMBER:14/15 Cert 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 TYPE OF INSURANCE S POLICY EFF POLICY EXP LTR POLICY NUMBER MM/ /Y Y MM/ i YYY LIMITS A GENERAL LIABILITY C01607P106TIA14 10/25/2014 0/25/2015 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY RENTEDDAMAGE TO 30Q 000 PR MISS a ogcurrenco $ r CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,000 }( OntraCtilal per PERSONAL&.ADV INJURY $ 1,000,000 CG0001(10/01) ^_ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO LOC $ B AUTOMOBILE LIABILITY 161OP516-14-CNS 0/25/2014 10/25/2015 COMBINED SINGLE LIMIT Ea accident _ 1 000 000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident _ Uninsured motorist combined $ C X UMBRELLA LIAB X OCCUR UP1841P816TIL14 0/25/2014 10/25/2015 EACH OCCURRENCE $ 6,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 6,000,000 DED I X I RETENTION$ 10,00 $ D WORKERS COMPENSATION B1613P6414-7-14 10/25/2014 10/25/2015 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 3A States: MA ME VT E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under ------ DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Leased/Rented Equipment C01607PI06TIA14 10/25/2014 10/25/2015 $50.000 Limit of Liability Installation Floater $75,000 Limit of Liability DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Covering operations of the insured performed during the policy term. Greater Lawrence Sanitary District is an additional insured on the general liability, auto liability and excess liability when required by written contract with named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Greater Lawrence Sanitary District ACCORDANCE WITH THE POLICY PROVISIONS. 240 Charles Street No. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Susan Gilman/SJG ACORD 25(2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved. INS025 onlnn.;t n1 Tha Ar:r1Rn nama and(nnn ara ranicfararl marlrc of At''non CO.,EWING ELECTRICAL INC. 3 North Road 37 DEERFIELD, NH 7-030 ___... _ ____ _ . lor3�_N ,� 2 'f ( 3) 463-9323 AT FEN nN TO WE ARE SENDING YOU :... Attached [.1 Under separate cover via following items: W] Shop drawings ❑ Prints EI Flans C:::l Samples L] Specifications ❑ Copy of letter C1 Change order CI COPIES DATE No, ` DESCRIPTION > , - _._. THESE ARE TRANSMITTED as checked below; f_I Fo�approva F] Approved as submitted [::. Resubmit _.__ copies for approval La Fo L::I Approved as noted L1 Submit __copies for distribution As requested ❑ Returned for corrections LL Return .._._.._.._.corrected prints CL.l For review and comment LLl ____. __.._._....___ _____ FOR BIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS ............. COPY TO_._._.__.._......_..._.._.__...._--- __ _._._..___._.........._.._.__..__.__.___ SIGNED: "nc If enclosur s are not as noted,kindly notify u