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HomeMy WebLinkAboutMiscellaneous - 37 KINGSTON STREET 4/30/2018N i Date ....t co.%ft.`a TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies fhat,,•.,j�A .. .. ................................. ......................................................... has permission to perform .... 91 wiring in the building of..... ................... ........ .......... .... ............. . .... , ...... . ......... ,North Andover, Mass. Fee.. '? /0Lic. No ....................... ........................................................... ELECTRICAL INSPECTOR Check # 7&o75 12780-/ Commonwea& of M'amaacktielb 2J P.ri`ment aI._i'ire Jeraice0 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only i Permit No. !� 1 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10/8/2015 City or Town of: N. ANDOVER 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) 37/39 KINGSTON ST BUILDING N Owner or Tenant C/O PROPERTY MANAGEMENT OF ANDOVER Telephone No. 978 683-4101 Owner's Address P.O. BOX 488 ANDOVER, MA 01810 Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. 20557075 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: REPLACE TROUGH ABOVE METER SOCKET Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires Swimming Pool Above ❑In- El rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. I Detection and lnitiatin Devices Ranges No. of Ran g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers beat Pump Number Tons J.KW........... .......... of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dyers Heating Appliances Kir Security Systems:* No. of Devices or Equivalent No. of Water K,W No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent 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 6Yires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 ❑x BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: Crowe & Sons Electrical Cor;n.a /-i LTC. NO.: 17 16 8A Licensee: James B. Crowe Signature V LIC. NO.: 17168A (If applicable, enter "exempt " in the license number line.) Bus. Tel. No.: (978)453-6696 Address: 590 Middlesex Street, Lowell, MA 01851 Alt. Tel. No. 453-6696 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001051 OWNER'S INSURANCE WAIVER: 1 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 Signature Telephone No. PERMIT FEE: $ 125.00 I f The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le2ibly Name (Business/Organization/Individual): CROWE & SONS ELECTRICAL CORP. Address: 590 MIDDLESEX STREET City/State/Zip: LOWELL, MA 01851 Are you an employer? Check the appropriate box: Phone #: (978)453-6696 1.✓❑ I am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3F I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ 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 proprietors with no employees. 5.M I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance., 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 1 l .❑✓ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *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. :Contractors 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: HARTFORD INS CO OF THE MIDWEST Policy # or Self -ins. Lic. #:13WECB79793 Expiration Date: 5/24/16 Job Site Address: 35-49 KINGSTON STREET BUILDING N City/State/Zip: N. ANDOVER 01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 herebv/certl;fv under the )453-6696 information provided above is true and correct. OCTOBER 12, 2015 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 #: ,...'P!,ease visit our web site at http://www.mass.gov/dpI/boards/EL CROWE & SONS ELECTRICAL CORP JAMES B CROWE (EL) 590 MIDDLESEX STREET LOWELL MA 01851-1428 Fold, Then Detach Along All Perforations C040MMONWEALTH OF MASSACHUSETTS AC40R" CERTIFICATE OF LIABILITY INSURANCE 76/3/2015 ) 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(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 New Agency Partners, LLC 99 Cherry Hill Road Shite 200 Parsippany NJ 07054 CONTACT Clare Belfiore NAME: PHONE(Q]3) 588-1800 AIC No: (973)588-1901 ADDRESS:cbelfiore@newagencypartners.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Selective Ins Co of South Carolina 19259 INSURED CROWE & SONS ELECTRICAL CORP 590 MIDDLESEX ST LOWELL MA 01851-1428 INSURER B :Hartford Ins Co of the Midwest INSURERC: INSURER D: INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER:15-16 Master rev 1 d 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY1,000,000 CLAIMS -MADE � OCCUR S 2151503 3/22/2015 3/22/2016 EACH OCCURRENCE $ DAMAGE TO RENTED 500,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY a JECT FX] LOC OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS-COMP/OPAGG $ 3,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL TOS X AUTOS SCHEDULED AU HIRED AUTOS X NON -OWNED AUTOS A 9093023 3/22/2015 3/22/2016 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE S 2151503 3/22/2015 3/22/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED I X I RETENTION$ NONE $ B WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 13WECBY9793 5/24/2015 5/24/2016 OTH- X STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) L,tK I It-IL:A It MULUtK UANL:tLLA I IUN Town of North Andover Electrical Inspector's Office 1600 Osgood Street Suite 2035 N. Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE re Belfiore/CIB (1-1 J.0��-�-1.-'xI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (9014011 Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................................................... 9--t _5-a.,v 19 D .A.4., . ...................... has permission to perform ......... . .................. wiring in the building of .... V.(.�.( P ............ ..L ................. /v a . t 36:.�j .. W-7,52D.>1r.. .P7:........" ..... ......,ZNorth Andoverass. 00 tYee..4T��. Lic. No. Lv.w ......... � 4 ........... MCM ICAL R 7 Check# 7/, `10631 t .om»rontuealth o�a�sachcs�ei �LJePartme►ct o��ire �eruices BOARD OF FIRE PREVENTION REGULATIONS Officiaal� /Use Only Permit No. Occupancy and Fee Checked ev. 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:_71&r]i r c ` City or Town of Q, I24fYlo0e ' To the Inspector of Win; 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 j Telephone No.9'79 Owner's Address Is this permit in conjunction with a building permit? ❑ No (Check Appropriate Box) Purpose of Building ' �� I �A--I Utility Authorization No. Existing, Service - F: urs ! Vo.:s 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: t , s t f ") U..,�,n 2Ca ► C ��r P{'(' 'ir—, 8ni 12.(1 oorn-, rmmnletinn nfthe fallnwing- table may he waived by the Insoector of Wires. No. -of Recessed Luminaires No: of . (Paddle) Ceil.-Sus Fans p No. of Total Transformers KVA No. of Luminaire Outlets • No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above E]In-❑ d. d. o. o mergency Lighting M Units . B Lfte 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 No. of Waste Disposers Heat Pomp Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW al Local ❑ Connection ❑ Other No. of Dryers Heating Appliances KW Securitio o Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No.'of Devices or Equivalent.. No. Hydromassage Bathtubs No. of Motors Total HP � . Ivo, of.L�edzces o= >; � e;;,elecommunications Wirinrut OTHER: Estimated Value of Electrical Work: Attach additional detail ifdesired or as required by the Inspector of wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 -11 BOND ❑ . OTHER ❑ (Specify:) t certify, under the pains and penalties of erjury, that the information on this application is true and complete FIRM NAME -Crowe & Sons of Cor LiC:NO.:-i7-168A Licensee: . James B. Crowe SignatureLIC. NO.: A (If applicable enter `exempt" in the license number line.) Bus. Tel. No.: �4-53-6696 .Address: 576 Middlesex Street, Lowell, a 01851 Alt. Tel. No.: (978) 453-6696 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. S.19 GO 001051 OWNER'S INSURANCE WAIVER: I am aware that the Licensee -does not hme the liability.insurance coverage normally .required by Telephone law. By my si ature below I hereby waive this requirement. I am the (check one E] owner ❑ owner's.agent. Owner Signaturreg PERMIT FEE. -S,55.001 e N� i i