HomeMy WebLinkAboutMiscellaneous - 126 Kingston Street \�
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Date.... /5
...................
OF NORTH
TOWN OF NORTH ANDOVER
to PERMIT FOR WIRING
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This certifies that............A!./C<. /.614... ....... .................................................
has perniission to perform ........ ........ .. .... .....................................................
. ... .
wiring in the building of ...... C.........................................................
. ........ f..........................I North Andover,Mass.
at .,......)........ ;r
Fee2O..............Lic.No. .. .......... J4.J..w
.......... ....... ... ..vj'--��
..................................
ELECTRICAL INSPECTOR
Check i ' 773ff
mJ-1 a CIL u-j C 7� Use Only
M
P(.iTTI)t No.
2,1
Occupancy and Fee Cncckc(l
5110
wfli FRA BOARD OF FIRE PREVENTION REGULATIONS [T Rev. 1/07)
Al,"PUCATM- NJ FOR PERPfi 1,T TCD P F`R F 0 R.M, E-1 E C T FZ 1,C A L VY 0 R K
All
C-Dd- I,Va:C
YE PRINT 1A1 INK OR TYPF,1./__G P\1F(j- R MA TIOA9
City or Twivii of: i o 13 1 S
TO "h
'Y this application 01C UnderSirA CS.
c •2ivcs icl- h is or 11C.'r iwentioll to Ilzr-forl-i-, ct7 iCa I rl�,described b=11o,;,,.
I aL
Location (Street.& Number)
Owner or Tenant
16
r ---,c c A C-1)t A�6
Is this PeTillit ill Conjull
cq-I
)udrflri2 permit? No [-'l (Check .-i..pprojjriace Bo:)
Purpose of Building
I L
L;dlity Authol'iZat'lio NO.
Existin- Service IU
Amps )qc, Volts Overh71 c:id -o. of Meters
New Senice -11�/d Amps 1,"_--!�2jkVolts 0 v e I II d I I d g r d
j N 0. of Ml t P.r
Number of Feeders and Ampacity
Location and Nature of Proposed I�".Iecfrical �rv'o—rk: ---
Lv
.0. of
1711,10,—omlcesspd 'Llimmiall,es I.N.'o. of ceu.-Susp. Fans i I ,
No. of'LLIrTlinlit-e Ojltl�rs
of Hot'rubs lGenerators
No. of Lurninaires A o r-n—
I-1- "o. 01
1.71atten
No. of Receptacle Outlets Ito. of Oil Burnet s
Is No. of Zones
No.
rN
IN-C). of G�is Bu.rners
N o. of Switches :1o. of Dett!�,ctioii all
Us
I.N"o. of Air Cori(]. oral
i-.111 00 Toils :N-). Devices
No. of Mste Disposers —K 717- N,
T, 0. C, :;!f-Contained
Devi-e� I
No- of Dishwashers spacr-..�-t�-a Heatilia 10�, P 2,
Connection
Ne. of Drvers Heatip.�.
10V
0.
0.01 REel,
H
S:S
01' -nt
S5 all Bathtubs
IN 0. of Motors To: (-TI !I ii i C.1 10 fl.N.
X
Ion(
_____ �___—_— elf
0 •
a uc o 0 DY pllllilic;-O• cy.)
INQUIP-0."ICE COVER-AGE: unlf�:z
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or} maj
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slich ol-,-
SS 0 1-
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FIRM NAANQ: C111
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LI C. IN 0.:
141, 1 1 9j
Pr
13115. Tel.Address: Te L "No.:
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/-01! 5CCUTity Y too
Pc r N'I. A I t. T�J- No.:
of Public z 7
AIVER., 1 dops nolh--.
icclilir-d �-v
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By illy si�:-;almre below, 7 -Zby V:7
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Signature No.
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- The Commonwealth of Massachusetts
' Department of Indus7rial,�lccidents
- .1 Congress Street, Suite.100
l;oston, MA 02114-20.17
www.mass.gov/dia
'Workers,Compensation Insurance Affidavit: Builders/Contractors/Electricians/I'lurubers.
A�
rlicant Information TO BE FILL?D WITH T.IIF,.PERNHTTING AUTHOR I'f Y.
Nalrie (I3ttsiness/Orgattizatiotr/Individual):_--(��— ^-� Please Print J,e iblV
Address: ;� % �l•l,� , —L --
`u
-_C1'tY/State/Zip:____j `� �,� — ------- - ----
Are yp nn employer?Check the apliropriate box: — -- ------------------ -- --L 'IV' ----
LL_jI am a employer with ( —employees(full and/or part-time).* T•YPe of project (required):—---
2.0 I am a sole proprietor or partnership and have no employees
ees working forme in 7• �New constmction
any capacity.[No workers'comp.insurance required.]
4• (] R.emodeling
�.L I am a hOmeo),vner doing all work myself[No workers'comp.insurance required.]t
9. r��7 Demolition
4 r]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Ll Buildinv addition
ensure that all contractors either have workers'compensation insurance or arc.sole , o
proprietors with no employees. 1.1.��"Electrical repairs or additions
5F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.•[]Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurancc.t
13. R-oof repairs
6.[-]We are a corporation and its officers have exercised their right of exemption per MG1.c. r
152,§1(4),and we have no.employees.[No workers'comp.it 1 ❑Other— ---- --
-- p tsttrattre required.]
q
]
''Any applicant that checks box 1 must also fill out the section below showing —
Homeowners w b heir workers'c --whosubmit� om �.tsa�'
ut this affidavit indicating P to.t policy ittfor a nev".
'Contractors
the are �.•
g y dome all work and Ihcn hire ou[ idc contractors must submit a new affidavit irdica;ina
Contractors that check t}tis box must attached an additional sheet showing the""name of the sub-contractors and state whet
employees. If theher or not Those entities;a;e
sc--i�contractors have em oyees,they must provide their workers'cain omp,policy mtrnber.
fornratdorr.an employer That is providing workers'compensation insu
inrance for my employees. Ijelory is the policy and joh site
.Insurance Company Name: (1 i�/✓ ` �.,(., „. r
Policy 4 or Self-ills.Lic..#:
SIJ c:� Expiration
Job Site Address:__ /1 S � ----
_ Crty/State/7-,r �t� (� is ,: ,r
Attach a copy of the workers' conn rsation policy declaration rage showing P_.-- ----n G _A
Failure to secure coverage as required under MG.1:.c. I52• I (showing the policy number and expiration date).
and/or one-year imprisonment,as well as civil penalties in the form c f a STOP WORK punishable
ORDER.andya fine of tip to S>>0.ne Up to UU
day against the violator.A copy of this statement may be for%yarded to the Office of Iuvesti, p OU a
--cover---age verification. ti, Of the DIA for inswance
—.I do hereby certi y und-e•the pat d nalties ofperj t the drrforarrrtiorz provided above is tare and correct. T
Si 1nature:—_
`1,13
�
Phone#: G i — - --
Ojftcdal use arly. .lJo not write in this area, to be completed by city or town official -- — --
City or Town:
Perrrrit/License#
Issuing Authority(cil•cle one): -- --` ------=--_—
I. Board of Health 2.Building Departurent 3. City/'I'own Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person:
--_-- --- ---- _-_----- Phone!f:
�l
ACCa)R jj
�.-- CERTIFICATE 4F LIABILITY 1NSURANC°E DATE(MMIDOryyyy)
THIS CPRTIPICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THI! CERTIFIC09/ 3/201
CERTIFICATE DOES NOT AFFIRMATIVELY OR NFGATIVE4Y AMEND, EXTEND OR ALTER THE COyERAQe gFPORDt'D ATE HOLBY THE POLICTHIS
IES
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 certiflcQlte holder Is an ADDITIONAL INSURED, the poltcy(Iss) must be endorsed, If 9UDROGATION IS WAIVEp SubJoct tD
the terms and conditions of the policy,certain policies may require an endorse A statement On this C3 rt 11:1 li :I does not confer rights to the
cortiflcete holder In Ileu of Stich endorsoment(s),
PRODUCER
Neill&Neill Insuron(:e Agency Inc David lorry
662 Riverdale Street PHONE (413 7
West Springfield,MA 01089 a IL
rtn�3u— )_ 32.4137
Al a13 731-669
INSt1 RCR 3 AFFORDING COVfiRAOU
INSURED Michael Farelll Electrical INSURER A I State Auto:insurance Company NAIc a
9 Applewood Lane INsuRsR s: Acadia Insurance
Methuen,MA 01B44 ----- 31325
JNB_Uj�ERp;
INSURPR P,
COVERAGES CERTIFICATE NUMBER INSURER F:
THIS 1S'i'0 CBR;IFY THAT THE POLICIES OF I SURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ASO FOR THE POLICY PERIOU
IN'OICATED. tiOT,VTHSREVISION NUMBER,
TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER ED N ME D WITH RESPECT T
CERTIFICATE I:AY 6=_ ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OF_$C(t10F.D HEREIN IS SUBJECT TO ALL THE TERMS,
EXCL'USfONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 0 WHICH THIS
Ix I — --- -
TYII OF INS:IRANCE
A 1 OENERAL LIABILITY FOLICYNUMaaR MM D
BOP?.7x5517 UMITE
i CON..VERCIAL GENSRAL LIABILITY 08/10!2015 08/10/2016 --
r GC40CCUAAeNCE i 1_000,000
7— OCCUR CLAIl.tB•MAOE !�' ' 4
- - i (�PA�M§E� - rc ncej_�3_ V 5�000
- --- ---- I MED ;P(Any ong ponon) I S V J,000
PP.RSONAL A ADV INJURY_ 3 1,000,000
I
G!,L AGGREGATE LIMIT APPLIES PER: OENSRAL AOORfiOATfi
7.,000,000
POLICY ,��RQi s
LOC r( PRODUCTS•COMP/OP
AGO S 2,000,
I AUTOMOBILE LIABIUTQ
00
I' � � I
I I ANY AUTO f —
(ALL'WINED919&S1d4e11 -
._,
AUTOS SCHEDULED
AUTOS CHE
BODILY INJURY(Par panes) S
!H:91!0 ALI NON-OWNED
AUTOb OODIIY INJURY(Ps(aoJdenq S
1°Ll�QL^� S
!UMBReLI.e
OCCUR i
~---�
"CESS WAN
I
^�
EO CLAIMS-MAD!! EACH OCCURRLNC(E 13
-T I N I„AAOOREOAT6 I S
B I wonKl!RS COMPFNEATION
AND t!MPLOY�RS'UABIUTY WC-20.20-001461-05
ANY PRO?RIFT ORn,ARTNEWEXECUTIVQ �Y-rN 03/20/2015 03/20/20
OFFICERIMIlMSER FXCLUDED7 I Y I 11A LLlf1
(Mandatory In NH) t-J E.L.EACH ACCID!NT
II Yee ne under F i 00,000
OE.16 1 1ceavlION OF OPF.RATIONB traiow E.L.DISEASE•_A
EMPLOYEE s tOG,000
E.L.nISEASfi.POLICY LIMIT S 500,000
DRECRIP T1nN OF OPERATIONS LOCATIONS/VEHICLES(A"--h ACORD 101,AddNonel Remarks SchaduD, n eoaes U ndulrvd)
Foxed to: 978-682-1480 Ir mo
I '
CERTIFICATE HOLDER
CANCELLATION
Town Of Nosh Andover SHOULD ANY OF THC ABOVE DESORI-5ED POLICIES BE CANCELLED BCFORI!
1600 Osgood Street,Building 20 TH Ex"ATION DATE THEREOF, .NOTICE WILL BE Da
Suite 2035 AC.ORUANCE TH TH?POLICY PROVISIONS. LIV!!RGD IN
North Andover,MA 01845
AUTHORIZED REP "SH AITV6
I
aI
ACORD 26(2010/06) 1986-2010 ACORD. ORPORA
The ACORD name and logo are registered marks of.'ACORD All rights reserved,
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