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Home My WebLink AboutWire Permit - Permits #13353 - 240 CHARLES STREET 6/4/2015 r r... Mill \\ } SELL I ate.... . . \ \ \ � \ . \IN kin iii AINTHNORTH \ \ 10 msw PERM-IT F �\ \ ' D `\ S� All o \ T @ 6 aisE¢Mf 'f 4 \ v a L+ gggl A� \' T ON O This certifies that \` OR , < wgw has permission to perform , s ............. wiring �n the building of ................................ North Andover, MassIN 11 . \ at ..................... IN ` IN \ 0. Lid. No. 3,.. g„ a I SF CTQR IN MW Fee... __... - LECTRIC L \ WINE NUNN Al 1eCC _ \ MAN INNERti; 0S \ Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rve . 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perflonned in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12,00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 512-1 It S City or Town of: Ajdove- r 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) 2400-ha'de's, �tr6-1- Owner or Tenant L.&W(19-11cR 57arlj7'44!�� Pj1>fyjCzTeleph*neNo. Owner's Address 2 62 c6a4le5 5-f- Is this permit in conjunction with a building permit? Yes No F1 (Check Appropriate Box) Purpose of Building k- A)tL� Y)Iv)7 Utility Authorization No. Existing Service Amps Volts Overhead❑ Undgrd F-1 No.of Meters New Service Amps Volts Overhead❑ UndgrdF] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I - P-1 17 b0/Ce /VI-A) J/)5,r&vme4,,A ci) dt 5 ftj Cam letlon 9f the following table ingy be waived b the Ins Irector of Wims. No. f T No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Tr o otal ansformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above n In- N-07-onmergency Lighting No.of Luminaires Swimming Pool grnd. grnd. Battey Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones f V No.of Switches No.of Gas Burners No.o election I Initiating Devices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices No.of Waste Disposers Heat Pump ....,!!inber I Tons I KW No.of Self-ContainZa Tot,72MIS0,11 ..........I-------------- Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local F1 Connection n Other Security Systems:; No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water No.of No.of KW Data Wiring: Heaters Signs Ballasts No.of Devices or Eguivalent No.Hydromassage BathtubsNo.of Motors Total lip Telecommunications Wirina: <j I OTHER: TMw No.of Devices or Eguiva-lent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Ejectrical Work: 120,00 0 (When required by municipal policy.) Work toStart C//I(Y—— Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVEkAGE: 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 5Q BOND F-1 OTHERE] (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete- FIRM NAME: eL�-�Ca Co -b� C- LIC.NO.: 1(099/+ Licensee:?�,I It f) _Signature 7�� LIC.NO.. A5 rlfapplicable,enter Bus.Tel.No.:&P-3 4&3 Address: - P0 604 10 Alt.Tel.No.: *Per k4Cjl,'c 147,s.57-61,security work requir�s Department of Public Safety"S"License: Lic,No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage non-nally required bytaw. By my signature below,I hereby waive this requirement. I am the(check one)F]owner n owner's went. Owner/Agent Signature Telephone No. PERMIT FEE: S The Commonwealth of Hassach usetts .Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov1dia Workers'Compensation Insurance Affidavit:Builders/Conti-actors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. AyWicant Information 0 Please Print Legibl Name (.Business/Organization/Individual):,, L,6i--..-C(6c.ft� kay Address: 6c) '31)(9 2 & C-<'2- City/State//`"`ip: __ L Are you an employer?Check the appropriate box: Type of project(required): L[J I am a employer with15 employees(full and/or part-time).* ]. El New construction 2.F-]I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. F-1 Demolition 3.E]I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10F]Building addition 4.E]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 11. Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F]Roof repairs These sub-contractors have employees and have workers'comp.insurance) 6.F-J We are a corporation and its officers have exercised their right of exemption per MGL c. 14.n Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box lit must also fill out the section below showing their workers'compensation policy infennation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now 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 employee,,,,they must provide their workers'comp.policy number. Iain art eniployey,tlzatis providing ivoi-liei-s'compensation insurance for iiiyemployees. Beloiv is the policy and job site information. Insurance Company Name:_,______ Policy#or Self ins.Lie.#:-A Expiration Date: [ Job Site Address: r , Co CAtA 5 11JI) 0(0 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 tinder 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 cera�fjy under the pa ittes ofpetjuiy that the information provided above is trite and correct, Signature: Date: A 4's Phone#: / —L J-/�- (o Official use only. Do not iprite in this area,to be completed by city or toivn 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 Phone#: MAY-29-2015(FRI ) 07: 00 P. 004/00d ONWF. I TH ORM' Sel SSJJ il) 40W,��1 R�kO MA31 r=�:L•E�1T�F 1 C I A A'swk f. ,t r • • - • • tj I C IA R { 91'+ i4�, t1 F I E.�. 11 o3p37; 14 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 5/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY 0.1 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(les) 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 A/C No. (603)224-e012 139 Loudon Road E-MAIL ilman@Towle a ene ADDRESS:s g g y'corn P.O. BOX 511 INSURERS AFFORDING COVERAGE NAIL# Concord NH 03302-0511 --`-- INSURERA?.Travelers dmnity Ine Co of Amer 001111- INSURED INSURER B:Travelers Indemnitv Co _— 25658 Ewing Electrical Co. , Inc. INSURER C:Travelers Pr9p Cas Co of Amer _ - -------- - — - PO Box 370 INSURERD:Travelers Indemnit Co of CT 001110 INSURER E: Deerfield NH 03037-0370 itJsuRERF: COVERAGES CERTIFICATE NUMBER:14/15 Cert REVISION NUMBER: THIS IS TO CERTIFY THAT TI IE 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. iwSR __._._ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN5R WVD I POLICY NUMBER MM/DD/YYYY) MMlDDIYYYY LIMITS A GENERAL LIABILITY 01607P106TIA1.4 1.0/25/201410/25/2015 EACH OCCURRENCE _ $ 1,000,000 _ X COMMERCIAL GENERAL LIABILITY DAMAGE TO R ENT ED PREMISES(Ea occurrence) $ 300,000 000 CLAIMS-MADE L'J OCCUR MED EXP(Any one person) $ 10,000 X Contractual Per PERSONAL&ADV INJURY $ 1,000,000 C00001(10/Ol) — - GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOP AGG $ 2,000,000 PRO - ) LOC $_._...-----..............__._._._........._---.. POLICY X I B AUTOMOBILE LIABILITY A161OP51.6-14-CNS 10/25/2014 10/25/2015 COMBINED SINGLE LIMIT 1 000 000 _(Eaaccident)_._e-_._----------.._$._..__.....__ ..,.__ _._c..-e_— X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Ut.F6 AUTOS AUTOS BODILY INJURY(Per accident) $ _ AUTOS _ " NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS $ _ (,Per accident) Uninsured motorist combined $ C X UMBRELLA LIAR X OCCUR CUP1841PB16TIL14 10/25/2014 10/25/2015 EACH OCCURRENCE $ 6,000,000 -- _.......... ... ...._.._._.._._... .__.... ._.._ ....---------...----- EXCESS LIAB CLAIMS-MADE AGGREGATE $ 6,000,000 DED 11 X T RETENTION$ 10,00 $ * WORKERS COMPENSATION 131613P6419-7-14 10/25/2014 10/25/2015 WCSTATU. 0TH- AND EMPLOYERS'LIABILITY Y/�N X I9RYJ 1M1L ANY PROPRIET"OR/PAR-rNER/EXECUTIVE - 3A States: MA. ME VT E L.EACH ACCIDENT $ 1� OFFICER/MEMBER EXCLUDED? � N/A 0001 OOO ----- (Mandatory In NH) E L DISEASE EA EMPLOYE $ 1 000 000 If yes,describe under _-_. ___ __...._ __._.._t,.. . t_..._..__..._ ,DESCRIPTION OF_OPERATIONS below _ — __ E.L.DISEASE-POLICY LIMIT $ 1,000 f 000 A Leased/Rented Equipment C01.607PI06TIA14 10/25/2014 10/25/2015 $50,000 Limit of Liability Installation E'loater $75,000 Limit of Liability DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Covering operations of the insured performed during the policy term. 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. Attn: Electrical Inspector 240 Charles Street AUTHORIZED REPRESENTATIVE No. Andover, MA 01845 y Susan Gilman/SJGL..sa ACORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. INS025 oninnFi ni Tho Af`npn nnma and Innn ara ranicfnrarl marls of Ar`.r)l