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HomeMy WebLinkAboutMiscellaneous - One High Street0 s r 2 CD �5 F - En fCqD CD e -t Date ..... q.-.. ?. q .... ... ...... .... .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This sz-;� . ! certifies that ....................... .............. has permission to perform ... 4! 5 �61 e .......... .......................... wiring in the building of ....... ezf �5�1 . . ........................................ at . . .................................. . North Andover, Mass. Fee./4i�� Lic. Nw!��.�?.-Y,7 ............. CrRICAL INSPECrOR 7 - Check �t //,�'q if - S4.0 41 a 0 WE a F.pleb'GUtid'ffCXL�GSfI'?."`'.C`3GLr:: Gni Gbr"b..�Gi�w�i u"iR.�� •�• 'JL1:a141 UJO lllL�'� Permit 1\10. �_' S(/f Ormer or Tenant B—O"'D OF FIRE PREVENTION F%E"GULATIONIS, Occupancy and ee 0 -Iced '� Ifrev. 11,/99] fieave olanl /_ A71�f .� ,.� t CSN -: 3 fui wori: to be nerrormed in accordance with the ]viassachusetts �tecci zl Code (JvZ—), -2, C1 [ i?.00 i:'LJ G 5� _111'`%T IIS 17 11, lJi? ti -:I_ t?L_ .11�''xll�1Y �LTl.?1�Ti i1?dte' city r Town i Gi(,Tj} •r1,TZb�1c-�✓' Bsf this zppiicatien tns Lneers-_ ed gives notice orin/sll e''. her Intenzoon to periform the electrical al work described below. Location (Street rveffiT+eal:'��o J`7`JL�7i'tq�� O+v,aPer'c A6dr ens ;JlisiriitPD SerALM / Wits New- Service Amps vol -t. - Number of Feeder. and gibsN9Hfl171D)ej:'QfFePQged'S2fiHQi( A -m ➢19cP$'d k,oeaTiiofl4 and Na$Ifl3'e of' -Proposed, LDeLi>raeap �1o>rD_' IS ins pe*Mt flfi8 COPY➢4Y5ACtE®ri wi$t, a JCCF3IlfldflfiLe HberaaaHt?' Yes ❑ No(CfiecD: Apgte�opflva$e Do--) �e��osa o}�eniiDdian� U$aaD>iy AeP$fioas:.altotP No. Overhead ❑ Undard ❑ vg'v"-.u' ;read ❑ U `'-ar d ❑ O Te:epfione No.%�r�� i a (nnmlolinn nfthc r'nl/n„.i... ,,.1,!„ . .r__ - �T - --:------.., ..._ ,....., ...... :. �.� --�,� n•u.<<•u� uv lrte. er7T_c-pecrnr n7 l4�lreS. lie..oI?� "e^,�SSem 1HIt,'$T.PCeS Ilia. of CenD.-Slfls�1. �ae�dle) �'9,i3S �T'�Cf. of - L ®tall No. of iIrlo. orHotTPPbs !Generators ...---- ��'�A •---� No. ®fLPs Ab®�I. e Z�ZJJ � G. ®E �Qe aefle�uPcG�gH$IIPg F�$nires.�'�SwPffiffiflPaPool iUCF-CID. B9$teCF% VJYPPtS Ivo. of Ilmeeep$QeDe Ou>iDe:S .—•--- No. of Oil )$la>raer-s 1�1� �PM5 No. or sones No. of Switches �a IiYIo. of Gas BiflII`IIIeCS o. of —Detection aflfl — Ini$ll289nE Devices ----------- No. --------Ivo. o€}c°.[anLyes rvo. of Ae>r CoffitD. Tow No. of ADeba¢aPa Devices ---� �Ig�anflflflp I I`dlPagflber I eons I;{tiVN Itis. of SeD� Oon$afl>med No.o. of�Vclas$eil�n5�osea`5 ea$ T®ta;i5: Deteegiom/><al:ectin6 Devices No. of Dishwashers �•.--�--� � Space/Area Hea$PIlPu KW.�— �,®Ca MffiII1DfGG'IgyDtal p�7 I j, } See ..f 1VQ. of Il'9r•�y7eC3 )�ea$GIflR 1'A1Dp6D2dG9CeS._.►��ti'gjSJ L7ee4JIII9Cy+ I'9�'SgeHPPu: CYM9 Iolo. of D�en�eces or l�'anflF'aDeIDt. I�io. o>< a$es o. or _ No. oh aea4eIl"SR'-----� 3'LW� � BaDD95$5 Da$9 Wiring:r.r-------� 8gagdg No. of Devices oC;v(azli='9Dpnt � II%. Hydromassage Ba$fi$t'nbs. IPdo. oi'MO$oub-----1T®i<aD E3FP--- 'I'ehecomimnunnc9lCfloEPS w nuacn aaaruuna! aemtl ij desired, or as required by the inspector of Wires. P?SUMANCI✓ COFTEA.GIE: Unless waived by the avmer, no permit for the peizornfance o; electrical wort: may issue unless the Licensee provides proal OT ilablhty insurance Incluoma `completed operation” coverage or its substantial equivalent. The undersigned certifies that such covera;e is in farce, and has exhibited proof of same is the permit issuing omee. CHECK ONE: IIdSUP�4.NCL`;� BOND ❑ OTHER ❑ (Specify:) • lrati Date) (t Value ofE ectri 1'dJork: (When required by municipal policy.) Work to Start: Inspections to be requested in accordant.. with MEC Rule 10, and upon completion. 1 CEPir�y, under hep decs ansa peaarafties of perju�, that the information net this 4appflcatiure as true and complete. FERM NAN;✓: • -` .Tnters-tate -Electrical Ser�Ti'c "Co l:"" � yE. A -� 17 --� 5.. ),aeeIDsee:.-Pas guale A. Alibrandi Saglaa$lare LIC. NO.: (!f applicable, enter "exempl "ill :he license � number line.) at s, Tel. No.: a a o n -7 Address: _ 7(1 Trohl o C'nNra RH N Pi 1 1 ori Car MA. - � _ _, R-43 0 01862 Alt. 1^eg No.: ©+V'P,'S EF4SLJ)<4"A-,I'dCE WA)lVE]lr: I am aware that the Licensee does not have the liability insurance coverase normally required by law. By my simature below, I hereby waive this requirement. 1 am the (check one)❑owner ❑owner's anent. Owner/Agent` Sem sa>rana-e Telephone N fl1rPFd5: „---- Trig oN Iwe�.cees or I✓anairaaDeIDt Teo. ®i"Meters No. o. vi Mete Date ..... (/-..( .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Pnw Ms certifies that .............. ... W .... ........... ... has permission to perform ............................................................................... wirmig *in the building of ......... .............................................. .A9- ...................................... ...... ....... , North Andover, Mass. Fee../:;�� Lic. NoJ.27�.,!��4 ........ '. I." . . g� i;;;rl.. � ...... EgELEemicAL INSPE - R Check L13 84/ A m 2 � ccco rmmonwealth olcc1//amac"tb NEW a1Jepartment o1..tim services $r BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL FORMATION) Date: City or Town of: M , a0 J�rL1—" To the Inspector of Wires: By this application the undersign d gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 0 t ah .S -f - Owner or Tenant \ZG/ 0 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Of No ❑ (Check Appropriate Box) Purpose of Building C-0mmQM60 Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ""`� j,, C(— t� tlparA bre Cninnletinn nfthe followine table may be waived by the Inspector of O'ires. No: of Recessed Luminaires No. of Ceil: Sus . addle F P (Paddle) No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA N, of Luminaires No., Swimming Pool Above ElIn- ❑ rod. rnd. o. o Units Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. In Detection and Initiatin Devices No of Ran es g No. of Air Cond. Total Tons No. of Alerting Devices No: of Waste Disposers P Heat Pump Totals: Number ... . ons KW ................. o. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Connection No. of Dryers ry Beating Appliances KW Security Systems: No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP W1 I TelecommunicationsNo. of Devices or E uivalent OTHER: 3500 Attach additional detail if desired, or as required by the inspector of mires. Estimated Valueof Electrical Work: 4i0�(When required by municipal policy.) Work to Start:() Q Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 IV BOND ❑ OTIIER ❑ (Specify:) I certify, under the pains ant penalties of perjury, that the information on this application is trite and complete. FIRM NAME: S. Donnelly Electric, Inc. LIC. NO.: 12649A Licensee: Steven Donnelly Signatur LIC. NO.: 23980E (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 5a —9 7— 7 3 Address: 31 Bedford Street, Lakeville, MA 02347 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires 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 normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent f PERMIT FEE: $ Signature Telephone No. T�yw 4 Date F...o."i ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1, 152- -0 1 This certifies that ............ - �.4 . . 6-11 . . ....... ................... il- . .... ..... .... ............. . .... ....... has permission to ........................... wiring in the building of ............ ................................................. at .... .................. ...................................... North Andover, Mass. Fee Lic. No . ............. ........ SP�� R Check# 840 Commonwealth of Massachusetts Department of Fire Services i BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.y4�� Occupancy and Fee Checked lam° [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: o _ City or Town of: NORTH ANDOVER To the Insp ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant C'9�py�,�� Telephone No.C�' Jeb - Owner's Address / ,t',— /-),AJ,-Ioza A)9. 01f/5' Is this permit in conjunction with a building permit? Yes ❑ No Er (Check Appropriate Bog) Purpose of Building 6"L4r- Utility Authorization No. „•. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Und rd g ❑ Number. of Feeders and Ampacity /jj,- A ,4 No. of Meters No. of Meters Location. and Nature of Proposed Electrical Work: �i:LoGQ>sDJ C1� �X�1'ry.✓ 1/ait[ t� �+ G:9�I1£: ✓/ ra% i/fl /I� �•�F �� aF /I/mvx Completion of the following, table may he waived by thv Incnortnr of Wirvc 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 Above11In- ❑ 2rnd. rnd. o. o Emergency ig g BatterV 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals Number - . ons ........... No. of Self -Contained DiApetinn I Uprting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other, Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. No. of No. of Signs Ballasts . Wiring: No. of Devices or Equi alent 76 No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �� (When required by municipal policy.) Work to Start: 4o/,p Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO GE: 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 (t✓ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complet& FIRM NAME: lAlf LIC. NO.: /i Licensee: 404 YA Qa, Z.a ` Signature LIC. NO.: (If applicable,, enter "exempt" in the license number line) Bus. Tel. No.: !&, —Z�u Address: .31 IXSS : CI?Aj . n,,- L'1Ca • �°:.:., /?.T qua! Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. AIA 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) F-1owner❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 I www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Atiplic$nt Information Please Print Legibly Name (Business/Organization/individual): L'LCc,-40 0A/2dlf LAli Address:_ 3C W� SVA. City/State/Zip:_ C' ; n,� /fid MPI Phone #:. /y 1)) Py 3- /l G J Are you an employer? Check the appropriate box: Type of project (required): 1.2'1 am,R employer with c� 4. ❑ 1 am a general contractor and I employees (full and/orpart-t.* have hired the sub -contractors 6. ❑ New construction 2. ❑ 1: am a.sole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling ship and have no employeesThese sub -contractors have 8. Q Demolition working forme in any capacity, workers' comp. insurance. 9, Q ,Building addition [No workers' comp. insurance 5..❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [Nonworkers' comp. c. 1.52, § 1(4), and we have no 12.Q Roof repairs insurance required.] t employees. [No workers' comp, insurance required.] 13.[] Other r+ny t appucanr mec mar enks boXit I must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this boa mustattaehad an additional sheetshowing• the name of the sub -contractors and their workers' comp. policy information. I am an em plr;yer that isproviding:workers' compensation insurance for my employees: information. Below is the policy and job site Insurance Company Name: /j7U71Jk7Znr �' ILI 9 ✓fz�R S' �_ Policy # or Self -ins. Lie. #:__- % % D� :36 /3& Expiration Date: / y Job Site Address: % />r� ��f Jyi - �i/ I�,✓17e�!/( �2Ip 60 [ City/%tezip: 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. I do hereby certify under the pains and #enaldes of perjury that the information provided above is true and correct Oficial use only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone #: ~ 4 _ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 41 Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner.of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance ' coverage 'required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es).and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self=insured companies should enter their self-insurance license number on the'appropriate tine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (.if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that, a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: r The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia i FACE EVIDENCE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 10/29/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Electro Standards Laboratories ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 36 Western Industrial Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cranston, RI ,02921 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone: 401-943-1164 Fax: 401-943-8631 INSURERS AFFORDING COVERAGE NAIL # INSURED INSURER A: St. Paul Travelers Electro Standards Laboratories INSURERB:''The Beacon Mutual Ins. Co. 36 Western Industrial Drive INSURER C: Cranston, RI 02921 INSURER D: INSURER E: vVv""^VL vQ 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSRNSRDD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A COMMERCIAL GENERAL LIABILITY TT06301328 11/01/07 11/01/08 DAMAGE TO RENTED PREMISES Eaoccurence $ 25000.0 MED EXP (Any one person) $ 10000 CLAIMS MADE X OCCUR PERSONAL 3 ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2000000 POLICY PRO LOC AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ 1000000 A ALL OWNED AUTOS BA6727LO75 11/01/07 11/01/08 BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $- ANY AUTO E OTHER THAN EA ACC $ AUTO ONLY: AGG $, EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5000000 AGGREGATE $ rj000000 A OCCUR CLAIMS MADE TT06301328 11/01/07 11/01/08 $ DEDUCTIBLE $ X RETENTION $ 10000 $ WORKERS COMPENSATION AND X WC STATU- 0TH - TORY IMITS EB_ EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 1000000 B ANY PROPRIETORIPARTNER/EXECUTIVE0000003174 11/01/07 11/01/08 E.L. DISEASE - EA EMPLOYE $ 1000000 OMEMBER EXCLUDED? yes. des If yes, describe under E.L. DISEASE - POLICY LIMIT $ 1000000 SPECIAL PROVISIONS below OTHER T I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS wr.r� nvwcn GANGELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN TOWN OF NORTH ANDOVER, MA NOTICE TO THE CERTIFICATE HOLDER NAMEOvT )HE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION ORjLI�BILITY�F jNqYKIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED A I\ . 10 Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that -.1- z�!7 A z . ..... Z& X has permission to perform .... f.r� ...... /I.rK*r/" 4�7 ......... wiring in the building of .......... 6g, 1, /. I/ ..C' I . ..................................... at ......... X/I 4 � .......... North Andover, Mass. -Z'0.0 -.-- .. � ............. Fee .................... Lic. No. . .. ... .... Check ,///7 4-.LECTRICAL INSPEWR; 8 4 1 5- r - ..•".�, taINUGDGUG�rS'UUiti?'��-i�GLr:': C'd� Gfir2'.���w�'iiva ���e viu�int va�vi1J: �_ _ en7 ��nn q rt Fe;T�itl�lo. re _ _ _ _ _ _ Occupancy ands C-heciced B��.^kRD C1 _ _ - 'Ii t= F)F_% 1 N ( _ 10N F-- =G�11 P. l 101 I�rBV. ll/441 cleave blank) s�,�. �� r A EFF; C; . P_�_hnF 70 P_FZ=0R R. _L E `��%� �:� Wer J ren All work to be t)erfotttted in accordance with the Massachusetts Mertrical Code .:?? r Yfl i 100 (r, AS� P, ;1NF E n' Iry : OP TYZ1 y LTi Date: 4 Cit�r ,00 ' h � - j Ln appli_atiorl tti� L T. derSL'led gives notice of I1:S " P,e' inLentlOn LG i lOrII til' ' l � Slt)e 'Delo ( 77,�� i pe ei� ri war - es� iQlzation (Street 4 1� 4Q�ber) OOvvmer or T'enane �oit% t/� Teiephoune Into. Owner's Address Le this pe=-ue>iit in conjunction with 2 building penin t? 1%es Ivo ❑ (Ciaee): AD )pante Box Purpose of Building � tiiiity Authorization No. Fiistiing Service �nps / VoltsCrver-head ❑ Und®rd ❑ No. of Meters New, Service Arai° p5 ! VO:4S g' ms'srd, � No. of M ❑ ��^ EJv aetezo Number of Feeders and rapacity /() Location and Nature of Froposed Electrical Woelk: Lo�� .L d I ('mm�iolinn hilae rn lln,.dnrr .., l,ln ». _a _ ,t__ 0 He.. of 1?ecessed FL -Lures _._._,..--.__. .., ...,. IIia. of, Cea-sttsp. (Paddle)Eans vie r Lv etc n• 44 0 t v Irw tnSoecror of Pires. G °f Total ransformers I, -VA Inc. ofF al t➢ o O tiets `.�--!No. of Hot Tubs Ideneraaors ---1 IIkI No. of Lighting Fnftu res Swimminv Fool A ov_ a Zn. a S—a nrnd. oe Emergency Lign nng leoatterw Units No. of Receptacle O utiets ING. of Crib Burners ALAPMS N7o. ofZones No.. of Switches No. of Gas Burners ---,ING. of Detecti-anal — finitiat9ine IIyevices - Ivo. of fi8a ages - No. of Air Cond. TotaTons i No. of leeaina Devices —_, No. of Waste Disposers ' eat p T otaIQ- Number I Tons Iva. of SeN Contained )Detection/Aierting Devices �--� I ------- No. of IDis>meI Mens - '----pace/Are! Heating K011 ILoct bio her ConnecNo. of Dryers No.. of'�+iaQes Heaters INo. Hydromassage Badntu eating Appliances '�^ No. of .- Ido. ®i Signs Bsuzsts `—"�I oflbilotors*��T®taP )ti[1�-----�Tetecoanmunications Security Security Sg'stenas: __r_.__ Ivo. of Devices or Eonuvalent jData Wiring: _ No. of Devices or Equivalient Wiring,: [NG. of ]Crevices or Equivalent F-3 79 EP : Attach aadutonal detail ii desired, or as required by the inspector of 4fiires. WSII.TULNCE CO�-T_Tr_-&GE. Unless waived by the ovmer, no permit for the p,rforniance of electrical wart: may issue unless the licensee provides proof of liability insurance including "completed operation" coverage Gr its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issum� om�v9 CHECK ONE: INSUR.ANCE� BOND ❑ OTHER ❑ (Specify:) -- Estimated Value of Electrical Work: 'c,�j (When required by municipal policy.) (t trail Date) Work to Start: � %�' Inspections to be requested in accordance with MEC Rule 10, and upon completion. F cet-tifY, Under tWpaitfs antd penalties of perjury, that the information on this appficadon is true and complete. FIRM NA*_NM: �/ /,r NO.: A; 5 21 7 Licensee: p�qua T e A A l ibrand; Signature%�� '�11�.I� LIC. NO,.: (if applicable, enter "exempt " in the license number line.) T may' s Tel. No-: o ] g Q n � E-430 Address: 7n Trh n1 ( oN7P p� NBillerica, MA 01 862 Alt. Tel. No.: " r ©IVk/N^1R'S 114SU)PA.NCE 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) ❑ owner ❑ owner's agent. Owner/ ae®> Sia PEP WIT FEE.- � 42: safruce Telephone o V, 0 Date.. A'9..— r2 Z?,:�9 TOWN OF NORTH ANDOVER PERMIT FOR WIRING a This certifies that.—,--,, .............. I ................................ has permission to perform_-.:�--.'.... ................................ wiring in the building of .......... at..Z.. .......... ................ ................. . North Andover, Mass. r rd Fee/' ........... Lic. No.1724VFO� .......... Check# 7 84-39 u A C.ccommonurealth of V 466ac4u-leib am )w aUeParineenf o��ire �ervice9 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. O y3 1 Occupancy and Fee Checked CELS 6r� [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: d City or Town of:� &ZrTo 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) 1 ; A\ S_ Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building `ZMM. T' 1C.\ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: !'n,nnlafinn n0he fnllnwinw table mai, be waived by the Inspector of Wires. Attach additional detail q aesirea, or as required Vy me JRSPectur q/ IT It ezi. Estimated Value of E ectri al Work: oQ (When required by municipal policy.) Work to Start: to a $ Ins ections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COV RAGE: 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 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and enaldes of perjury, that the information on dtis application is true and complete. FIRM NAME: S. Donnelly Electric, Inc._ LIC. NO.: 12649A Licensee: Steven Donnelly Signatur -� .,�.��� LIC. NO.: 23980E (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 5O -9-9 +$— 77- 7-43 Address: 31 Bedford Street, Lakeville, MA 02347 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires 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 normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent I PERMIT FEE: $1f Signature Telephone No. No. of Total No. of Recessed Luminaires No. of Ceil: Sus Fans P (Paddle) Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency ig in Batte Units 3 No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones Gas Burners No. of Detection andInitiating No. of Switches No. of Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices Heat Pump umber Tons KW o. of Self -Contained No. of Waste Dis osers P Totals: .......... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection El Other Dryers No. of D ry Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Total HP Telecommunications No. Hydromassage Bathtubs No. of Motors Equivalent No. of Devices or E uivalent OTHER: Attach additional detail q aesirea, or as required Vy me JRSPectur q/ IT It ezi. Estimated Value of E ectri al Work: oQ (When required by municipal policy.) Work to Start: to a $ Ins ections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COV RAGE: 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 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and enaldes of perjury, that the information on dtis application is true and complete. FIRM NAME: S. Donnelly Electric, Inc._ LIC. NO.: 12649A Licensee: Steven Donnelly Signatur -� .,�.��� LIC. NO.: 23980E (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 5O -9-9 +$— 77- 7-43 Address: 31 Bedford Street, Lakeville, MA 02347 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires 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 normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent I PERMIT FEE: $1f Signature Telephone No. q 4. - The Commonwealth of Massachusetts a Department of Industrial Accidents t Office of Investigations d 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/orpnization/Individual): 1 _ kc, 'Tnc Address: City/State/Zip: L&.VEv i � �R., (� � Phone #: Are y an employer? Check the appropriate box: ,.Frey . I am a employer with 4. ❑ I am a general contractor and I employees (full and/orpart time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' conip.'insurance 5• ❑ We are a corporation and its. required,] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required..] Type of project (required): b. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9 iidding addition 1 ctrical repairs or additions, 11. Plumbing repairs or additions . 12.❑ Roof repairs 13.[:] Other' *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy infonnation: t Homeowners who submit this affidavit indicatink 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 their workers' comp. policy information. I amt an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site jtb,. _1eAC Expiration Date: City/State/Zip: JV . Myd0 41Q� NPS,. 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. I do hereby certify under the pains and penalties of perjury that the information provided abJ,,A� ve is truet: 1and correct Sienature: Date,— 0 I �� �0 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 5. Plumbing Inspector 6. Other Contact Person: Phone #: mil vn Report Date: 07/15/08 Project Owner: Est. % of Completion:50% Present: Name Klarens Karanxha Field Report East Mill, 1 High Street North Andover MA Field Report Number: 04 Conformance with Schedule: Report by: CompanX Contact Phone & Fax / Email KDI 61.7-591-8682x122 / k"xha@tkQeast.com DATE:08/05/08 TIME: 3:00pm WEATHER: sunny TEMPERATURE RANGE: 80-82 PRESENT AT SITE: Klarens Karanxha I KDI 617-591-8682x122 kkaranxha@tkgeast.com David Steinbergh (DS) - RCG LLC; dsteinberjzh@rcg-Ile.com Peter Kaplan (PK) - RCG LLC pkqplan@rcg-llc.com c.com Skip Rose- RCG Builders LLC; srose@rcg-llc.com Kieran Whelan - RCG Builders LLC kwhelan@rcg-llc.com 1.1 Demo workers 1.2 Framers 1.3 Plumbers 1.4 Electricians 1.5 Superintendent WORK IN PROGRESS: 1.6 Rough plumbing work is complete. 1.7 Rough electrical work is complete. 1.8 Ducting materials placed on the third floor. 1.9 Electrical work is in progress on both levels. 1.10 Plumbing work is in progress on the third floor. 1.11 Ductwork is 90% complete at both levels. 1.12 Model unit # 3001. Framing complete. Plumbing is complete. Electrical work is in progress. 1.13 Electrical work has been completed in both levels and is ready for wall gyp. NOTES / DIRECTIVES: ITEMS TO VERIFY: Any product material provided is for reference only and does not relieve the contractor from providing shop drawings for the actual materials being provided and workmanship in accordance with the General Conditions of the Contract and State Building Code standards. Discussions during this meeting have been recorded as understood by this writer. If there are any omissions or corrections, please contact the writer. Unless notified to the contrary within ten days of receipt, these notes become the official record of this meeting. Attachments: Distribution to: all attendees, Building Inspector, Project File, Owner Khalsa Design, Inc. Page 1 of 1 � A Field Report East Mill, 1 High Street North Andover MA Report Date: 09/29/08 Field Report Number: 05 Project Owner: Est. % of Completion: 70% Conformance with Schedule: Report by: Present: Name Company Contact Phone & Fax / Email Klarens Karanxha KDI 617-591-8682x122 / kkaranxhanatkgeast.com DATE:08/20/08 TIME: 3:00nm WEATHER: sunny TEMPERATURE RANGE: 80-82 PRESENT AT SITE: Klarens Karanxha KDI 617-591-8682x122 Jai Singh Khalsa KDI 617-591-8682x111 Kieran Whelan - RCG Builders LLC 1.1 Framers 1.2 Plumbers 1.3 Electricians 1.4 Superintendent WORK IN PROGRESS: kkaranxha@tkgeast.co jsingh@tkgeast.com kwhelan@rcg-llc.com 1.5 Ducting materials placed on the third floor. 1.6 Plumbing is complete on both levels. 1.7 Ductwork is complete at both levels. 1.8 Maxon flooring system is in place. 1.9 Model unit # 3001: Drywall installation is complete 1.10 Electrical work has been completed in both levels and is ready for wall gyp. NOTES / DIRECTIVES: All electrical boxes along the corridor walls have to be fire rated or covered with fire rated putty. All tubs installed up against corridor walls and demising walls should have a continuous layer of GWB behind the interior face of the wall. ITEMS TO VERIFY: Any product material provided is for reference only and does not relieve the contractor from providing shop drawings for the actual materials being provided and workmanship in accordance with the General Conditions of the Contract and State Building Code standards. Discussions during this meeting have been recorded as understood by this writer. If there are any omissions or corrections, please contact the writer. Unless notified to the contrary within ten days of receipt, these notes become the official record of this meeting. Attachments: Distribution to: all attendees, Building Inspector, Project File, Owner Khalsa Design, Inc. Page 1 of 1