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Home My WebLink AboutMiscellaneous - 8 KINGSTON STREET 4/30/2018 (2)Date ........... W.�A ................ commonwealth of k7amacLeta 2eparEmeni ol._i'ire Services BOARD OF FIRE PREVENTION REGULATIONS 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: OCTOBER 24, 2014 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) 8 & 10 KINGSTON STREET Owner or Tenant VILLAGE GREEN CONDO ASSOCIATION Owner's Address C/O PROPERTY MANAGEMENT OF ANDOVER Telephone No. 978-683-4101 Is this permit in conjunction with a building permit? Yes ❑ No ❑� (Check Appropriate Box) Purpose of Building RESIDENTIAL Utility Authorization No. 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: REMOVE AND REPAIR CONDUIT AND WIRE AS NEEDED DUE TO INSTALLATION OF SOFFIT VENTS Completion of the jollowinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires Print Form Official'Usse Only Permit No. I1U ` Occupancy and Fee Checked [Rev. 1/071 (leave blank) Generators KVA Q - 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: OCTOBER 24, 2014 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) 8 & 10 KINGSTON STREET Owner or Tenant VILLAGE GREEN CONDO ASSOCIATION Owner's Address C/O PROPERTY MANAGEMENT OF ANDOVER Telephone No. 978-683-4101 Is this permit in conjunction with a building permit? Yes ❑ No ❑� (Check Appropriate Box) Purpose of Building RESIDENTIAL Utility Authorization No. 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: REMOVE AND REPAIR CONDUIT AND WIRE AS NEEDED DUE TO INSTALLATION OF SOFFIT VENTS Completion of the jollowinQ table may be waived by the Inspector of Wires. 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 Above ❑ In- El rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ............ . Tons ............... . KW ............. No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Cyonnection No. of Dryers Heating Appliances KW SecN of 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 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: $1,265.00 (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 ❑✓ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: CROWE & SONS ELECTRICAL CORP. /-\ n/) t, _J LIC. NO.: 17168A Licensee: JAMES B. CROWE Signature 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.: 978-453-6696 *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 Signature Telephone No. PERMIT FEE: $40.00 1�44 �, + :70.00 = $110.' The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations p. }` v_ i 600 Washington Street Boston, MA 02111 :vr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CROWE & SONS ELECTRICAL CORP. Address: 590 MIDDLESEX STREET : LOWELL, MA 01851 Phone#: (978)453-6696 Are you an employer? Check the appropriate box: 1. El I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ r required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.® Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ 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 ani an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Utica Policy # or Self -ins. Lic. #: 4755523 Job Site Address: 8 & 10 KINGSTON STREET Expiration Date: 5 / 2 4 / 15 City/State/Zip: N ANDOVER, MA 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 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 herehy, ertky under the_pAls and penalti perjury thane information provided above is true and correct. OCTOBER 24, 2014 78)453-6696 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 b. Other Contact Person: Phone #: ® A� o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYYI 10/30/2014 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 Insurance Marketing Agencies, Inc. 306 MAIN STREET Worcester MA 01608 CONT NAMEACT Tracy Campbell PHONE 508-753-7233 FAX No,. 508-754-0487 E-MAIL . tic@imaagency.com INSURERS AFFORDING COVERAGE NAIC # 4745767 INSURERA:Utica Mutual Insurance Company 25976 3/22/2015 INSURED CROWE INSURERB:Acadia Insurance Company 11295 INSURER C:Republic Franklin Ins. Co. Crowe & Sons Electrical Corporation INSURER D: 590 Middlesex St Lowell MA 01851 GENERAL AGGREGATE $2,000,000 PRODUCTS -COMP/OP AGG $2,000,000 INSURER E: INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED X IAUTOS NON -OWNED HIRED AUTOS X AUTOS fcrTr CrP`ATC r.urenmcm 1000c;')RAA7 R9VICI(11J NI IMRFR• 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 INSURANCEADDLSUBR INSD WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS C JDAMAGE c X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR 4745767 /22/2014 3/22/2015 EACH OCCURRENCE $1,000,000 TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO ❑LOC JECT OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS -COMP/OP AGG $2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED X IAUTOS NON -OWNED HIRED AUTOS X AUTOS MAA5144759 /22/2014 3/22/2015 COMBINED SINGLE Ea accident LIMIT $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS LIAB HOCCUR CLAIMS -MADE 4745768 /22/2014 3/22/2015 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED X I RETENTION$0$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE � OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 4755523 /24/2014 5/24/20.15 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYE $500,000 E.L. DISEASE - POLICY LIMIT 1 $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) /^COTICH'ATc Unl noo CANCFI I ATInN iJ 1988-2014 AGUKU GUKPUKA I IUN. All rlgnts reserve/]. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. ELECTRICAL INSPECTOR'S OFFICE 1600 OSGOOD ST BLDG 20 #2-36 N. ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE iJ 1988-2014 AGUKU GUKPUKA I IUN. All rlgnts reserve/]. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD P.l,;ease visit our web site at http://www.mass.gov/dpl/boards/EL Y CROWE & SONS ELECTRICAL CORP JAMES B CROWE (EL) 590 MIDDLESEX STREET LOWELL MA 01851-1428 Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSA&USETTS .:�,!1,��'�J�;1(�],�I:a:toJa�►'2•`i of l►l-\t14[aia►b'i�l:i�= � BOAARD DF' €LE>CTR I C I A:N;S;;=;<;<<_ ` ISSUES ..THE;FOLLOWING ">L 1C E NSE A STERED MASTER ELECTRICIAN m a CR.OW'E & SONS ELECTRICAL CORP., ,. ; .JAMESB .CR0WE STREET 590 MIDDLESEX :: 01851-1428 is"> 1$:<;_p,>`>`:. 07/:3:]/t6'>`< 57010 716