HomeMy WebLinkAboutMiscellaneous - 106 Kingston Street `\
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TOWN OF NORTH ANDOVER
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PERMIT FOR WIRING
s`QACHU
This certifies that ...............A
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has perinission to perforni . nn
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wiring in the building of.......... ............................................................
at
............ ..... .......North Andover,Mass.
Fee..7p.
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ELECTRICAL INSPECTOR
Check#
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-C/'"'J 01,1`16A Use Only
in OF 01
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OCCUPTIC)' and Fef-
BOARD OFFIRE PREVENTION REGULATIONS
(lC?vv Wank)
AFT-PUCAT[ONJ FOR PDERN"HTTO F2EF'-:,'FC I rA, ELECTF,'NCAL WORK
All work to be pri jormed in accordance
wi:h !'ihc
I ..-1.- � q;:.Fjj COd- I" 1E C) 527 7 CM TZ 1 0,0
('P L 4 SE PRINT IA/RN tr, OR 7iV'YF F A,.1 IL 1�F,J)R A 7701y) D a to: )7- ' '
Ci ty or To wn of: oy
By this application the undersiry
C,Ijt,,u vivcs -:o',.)cc o his or her inicliltioll to X-1-Toril-I �'F!K described bck,'y.
Location (Street& (\lumber)
no G4
Owner or Tenant
IRT. er's A"."'. N -
tS th:s perillit ill Co[ u j
-ijuric"
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Purpose of Bulld i Il o �_heck so:)
1,;filiry Authorization No.
Existing Service
A.m p s P_a/_0_YPVOlts 0 ve r I I ca d Unclard Ev__�
No. of Meters
7-1
NLI�!S�Iyice A.n1ps Ul o. of.Metevs
la�L LIZ3movolts Overhead
Number'of Feeders and Ampacity
_--
Loma Ion and Nature of Proposed Electrical Wcr�
k:
-A
NO. of Recessed ILAIMINlaii-s
Of Ceil.--Susp. F
ans
:Trarisfor-incr-sV.A
No. of Luminaire Outlzts j.
o. of Hot Tubs lc'en�!I-'Itors
No. of Luminaires �.Swi!nrnintr Pool AmvC --I In- No' of
Lin 2vnd. L 1'
-�- I
B)a(ter
No. of Receptacle Outlets No. of Oil Burners -IT"'El ALARMS jNo. of Zonf.,s
No, of switches lNe. of Gas Burners CU!Cnoll all
I. of Ranges .No. of.-Ail- (_"orld,
i-In"O Tons :N'o. C-f Devices
N`0 Of Waste Disposers 1 I.—Pu'T—' liai I
I 10Y o. ci 0 fie
................
15
Device-
No. of Dishwashers
i rl 2 1
if)21
Heatilia 11"'W
Con ection
Ne. of D ry c rs Heating .-,Lppliancev Z'
v i C s 0
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si2lis E" llp.s:s
�'V!Ces cr,
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N o. I
.). c I Devices or
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00
mated Value ofElect-caj JI
y Dolicy.)
i7i a;ordance with u!c
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n on.
U rv_0`C,K_c wov "d 7 1)�Tljjit for II)e Ptffo;-Tn:�jI(,t" t
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iNSUP-A-INCE 'kVAIVER.- I Liccils"I.C,dor,nes not/?f-.7 -.A
I(,q I 11 r-_d 't-v 1 il)'siir�nf:2 C;. ___
R MY si�77�'Liirr below',
'IT, T. t) E] C
0�v n c r''A!,e ii i L
Siorn2ture"
47) Ilse Common wealth o f Massachusetts
Department of'Industrial,4(, nts
^ , 1 Congress Street, Suite.100
Boston,.MA 02.714-20.17
www.mass.gov/dict
Workers, Compensation InsuranceAffidavit: Builders/Contractors/Electricians/Plumbers.
Applicant Information To BE FJLI!,D WITH THE I E10,IITTING AUTHORITY.
�— Please Print Leaihly
aTriePlease
<
Address:A Ui
CI
/State/Z,1��-
--- �----- -�-=..t 1 -�''_���` -���� Phone �#•_t�'' �i,1_ �;'�.,t�; �,j.�L--- �------
Are y an employer?Check theaPI pro riat --- --- ---—----- --- —
P c box: ----- -�.—.--.___-_.---
I.1Iamaemployer wlth ( q'ype Of project(required):
—1 L—employot:s(full and/or part-time).'
2.0 I am a sole proprietor or partnership and have no employees working, fin'mne i 7. E]New constnrction
any capacity.[No workers'comp.insurance required.] 4. [r-] R.emodelin
-t.L-]I am a horneovmer doing all work myself(No workers'comp.ins 1J• t_ Den t
1 urarlcr.required.]t --� z�lrtion
4.Ellamahomeowner and will be luring contractors to conduct all work.on my property. I will 10 U Burldirig addition
enswe that all contractors either have workers'compensation insurance or arc sole
proprietors with no employees. 1 I.11f"F,lectrical repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached.sheet. 12.E]Plulllbing repairs Or•additions
These sub-contractors have employees arid have workers'comp.insuranco.i
13.0 Roof repairs
6.❑we are a corporation and its officers have exercised their right of exemption per MGI,c, 14.r Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.] ❑ ---- --
`Any applicant that checks box tl must also fill out the section below showing their workers' tion
l Homeowners who submit this affidavit indicating they are doing all wcompensatio!t policy information.
work and then hire outside contractors must subnut a tion affidavit irdicatin�_!ch
'Contractors that check this box must attached art additional sheet showing the name of the sub-contractol:s and state whether or not those entities;;ave
employees. If the sub-contractors have employees,they must provide their workers'comp.policy mrrnber.
— —----- _
ant an employer that is prnvidinel workersm
i pen
information. 'cosation insurance,for my empl�iyees. Below iy the poliy amd)ob site
.Insurance Company Name:
Policy;or Self-ills.
---�`.-- _�_�' l�� Expiration
Date:.--
Job
Site
Address:
Attach a co "QCa—
--_-.City%State/7-,ip: A�'! , ���,iiipy of the workers ensation policy declaration page(showing the policy number and expiration date).
L,
Failure to secure coverage as required underlvlG.I,C. 152; §25A is a criminal violation punishable by a tine up to 51;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 S250.00 a
day against the violator.A copy of this statement may be forwarded to the, Office of IuvestiMt'
coverage verification. ;, cons oCthe DIA for insurance
I do here bScel-tif+y� der-th pa s ar1dpenalties o f penury that the iformation provided alcove is true and correct.Si�rrature: Date ---�Phone "-—1
Official use only. Do not write in this area,to be completed by cit}7 or town official.
City or'Tow°: — Permit/License
Issuing Authority(circle one):
1.Hoard of IIealth 2.Building Departurent 3. City/'I'own Clerk 4. FIectrical Inspector i. Plumbing Inspector
6.Other
Contact Person: _-------- ---- Phone It:
ACcaRb®
CERTIFICATE OF LIABILITY INSURANCFE DA0910312015 )
TH18 OCRTIPICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS, UPON THR CeATIFICATE HOLDER. THIS
09/031zp15
CERTIFICATE DOES NOT AFFIRMATIVELY OR NFGATIVEL,Y AMEND, EXTEND OR ALTER THE GOVERAGt? AFFORDCD t!Y THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUYE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT; If the CeRiflcete holder la an AUU11IONAL IN8 REP, the pollcy(I.III mu!I ba andoraed. If SUBROGATION IS WAIVED subJoct to
the terms and conn 11011 s S the policyender,certain pollclo9 may require en 811dOrSPITlent. A statement on this cortiticate does not confer rlght�to the
cortiticate holder In Ilett of such endoraoment(a),
vR000CER
Neill&Neill Insurance Agency Inc David Jarry
882 Riverdale Street PHONE
West Springneld,MI,01089 _H21111: (41 3)732.4137 _
E•M IL — arc NeL(413)731-6629
INSURGR S AFFORDING COYCRAOG
INSURED Michael FarelllElectrical INSUMBRAl State Auto:lnsura_nce_Company NAIC#—.--
9 -
9ethuen,M Lane INSURRRa: Acadla Insurance Co, STA
Methuen,
Methuen,MA 01844 --- =
SURER __.___._ _� 31325
INc,
INS RPR P r
l
INSUK
CovERAGEs E'
RF;
THISC,EKTIFY THAT THE FOLIC cSROF�I WUR 'I'll I�S�E 18ELOW HAVE BEEN ISSUED TO THE INSUK
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONI REVISION NUMBER:
CERTIFICATE MAY 8E ISSUED OR MAY PE D TION OF ANY CONTRACT OA OTIIER DOCUMENTnWI071V{CREBPECT TO WHICH THIS
EXCLUSIONS AND CONO;TIONS OF PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED Hp SPECT 16 SUBJECT TO ALL THE TERMS,
SUCH POLICIES.LL�AITS SHOWN_MAY HAVE BEEN REOLICED 8Y PAID CLAIMS.
Lv RR _`--------- ..�._.
T"I Of INSURANCE '�
A 1 GENERAL LIABILITY �~K�POLICY NUMIAR _
BOP7.745517 MM p ) M—/pprY l� LIMITS a
h !COMv.ERC1AL GENE 2 108/110/2015 10011012018 _
RAL LIA IUTY I l EAC4 OCGURR2NCE 3 1_000,000
CLAIM$-!/Apt I�t OCCUR PA MI
MED EXP An one uson 5,000
P!RSONAL dADV INJURY 3 1.000.000
I
U!N'LAGG,REGATELIMIT APPLIESPER: OEN6RALAGORfiGAT6
S 7.,000,000
�L I POLICYf I PR ' LOC PRODUCTS•COMP/OP AGO b 2,0 .000
l AU1 DEILE LIAEIUTY
`—i S
ANY AUTO t:A.AF6iG ._
(ALL OWA'EO I1t11
AUTOS 9CHEOULEO AII INJURY(Par ponon) S
j_ U
'I HtR!C AUTO& NOT09�Wr1Ep III
N
AUTOS, OOpILY INJURY(Per sac)Csol)
PR
tP:!OPERTY')pAMA�—GE""--
I UMCRCLLA LIAR
I i
9X1,113119X1,11311 L'AI OCCUR
CLAIMS-MAD! �✓1C11_OC CURRINCC 11
_DED I I I ACT()AEOATe
Q WORKERS COMPlNSATION l
ANO!MPIOVlRB UASIUTY WC-20.20•p01461.Ob 03/20/2015 031201 Oi �� f ASU.
ANY aROpRIETOR?AATNB YIN ~`�� IIrLLM? I -�s^`�
—-
Opp'CF I!MMCI!FXCLUD pp ECUTIVe lam;--I N1 A 0_H.
(Man defdry In NH) U C.L.EACH ACCID!NT
Iflea deernbe under f __,00,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE•EA EMPLOYEE 3 1
— _— — _ 00,000
POLICY LIMIT S Wu 51010,0100
ORSCRIPTION OF OPIRATIONS 1 LOCATIONS/VEHICLES (Attach ACORO 301,AddIdOnsi Remarks Schedule,If mon space 4 mQulred)
Foxed to: 978-682.1480
CERTIFICATE HOLDER
CANCELLATION
Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
16100 Osgood Street, Building 2D TH EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVERED IN
Suite 2035 AC.ORDANCE TH THE POLICY PROVISIONS.
North Andover,MAO 1845
AUMORIZEDREP 'S6 ATNE
I
ACORD 26(21010/06) The ACORD name end logo are regia ared marks ofACORD-2010 CORD ORPORA All rlgntB reserves.
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