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HomeMy WebLinkAboutWiring Permit - Building Permit - 123 BONNY LANE 9/22/2014 4. Date. . �................ OF 0 Th qM r .., oom TOWN OF NORTH ANDOVER O p PERMIT FOR WIRING 8�1CHUg� This certifies that ... .. ..v . ... .`.'.: ... ., .. )'. y has permission to perform ,:- ....F: ..r... . .................................. wiring in the building of...,......,:.,.............. i D at ... t.r ... ...... q� t� 6 ; , North Andover,Mass. Fee E. ��... Lic.Nod ..... ........................... ELECTRICAL INSPECTOR �� , Check# h u i (-Ommoftwfaa Of frIa"aclumem Official Use Only rA®v,PM ®`3im wk." Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATfOR, FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12,00 (PLEASE PRINT W XK OR TYPEALL FORMATION) Date: n( I l (7 )4 City or Town of: �K k lodar- 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 do Number) ( 3 Owner or Tenant Telephone No ? Owner's Address fx-v— Is this permit in conjunction with it building permit? Ives ❑ No Check Ap propriate ppropriate Box) Purpose of Building 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 t l Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Ins eetor of Wires. FNoof ecessed Luminaires No.of Ceil.-Susp.(Paddle)Fans °•° Total Transformers KVA uminaire Outlets No.of hot Tubs Generators KVA uminaires Swimming Pool Above ❑ In- ❑ o.o in ig ng rnd. rnd. Batte Units eceptacle Outlets No.of Oil Burners ALA S No.of Zones No.of Switches No.off•Gas Burners o.o etection an Initiating Devices No.of Banger No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pump _..am.•.er Tons o.o S - ontain Totals: ....... .............__... ..............._.W • Detection/Alertin Devices No.of Dishwashers Space/Area heating KW Local umcipa �SCConnection ❑ der No.of Dryers heating Appliances Security ecNu y tDevices or Equivalent r o.o heaters ater No.of °'r--�Data Wiring- Signs Ballasts No.of Devices or Equivalent No.hydromassage Bathtubs No.of Motors Total HP ecommunicahons inng: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires, Estimated Value of,El ca Work: `[l� (When required by municipal policy.) Work to Start: 1 t Inspections to be requested in accordance with WC 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 Q BOND ❑ OTHER ❑ (Specify:) P certify,under the pants and penalties of perjury,that the information on this application is true and co let FIRM NAME: Nigh atch Protection Inc. LIC.NO.: 7024C Licensee: Paul Delsignor Si ature � LIC•N®•:7024C (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:888-722-9282 Address: 22 Briarwood Drive, Westford, MA 01886 Alt Tel No.: ; *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. SS-001696 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 Signature Telephone No. �ERhl9illTF'EEe �j5 V�. �,r� i ��` e 6>0 '1 61'"Al "e:F"YtrrgCng ai-ina strialACCiaenls ®ice of Investigations I Congress Street, Suite 100 Boston, AM 02114-2017 www-mass 9ov/dia Workers' Compensation Insurance Affidavit: B ' tiers/Contractors/Electricians/Plumbers Applicant Information Please Print LeLribly NaMe (Business/Organization/Individual): Nightwatch Protection, Inc. Address: 50 A [Northwestern Dr. Suite 9 City/State/Zip: Salem, NH 03079 Phone #: 888-722-9282 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 13 4. ® I am a general contractor and I 6 New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling ship and have no employees These sub-contractors have g• F1 Demolition working for me in any capacity. employees and have workers' insurance.$ 9• ❑Building addition comp.[No workers' comp.insurance required.] 5. ® We are a corporation and its 10.❑Electrical repairs or additions 3. officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13 OtherSec.Syst-Low Voltage comp, insurance required.] my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have iployees. if the sub-contractors have employees,they must provide their workcrs'comp.policy number: trans an employer that is providing workers'compensation insurance for rosy employees. Below is the policy clod job site formation. wrance Company Name: Hartford Insurance Co. of the Midwest licy#or Self-ins. Lic. #: 76 WEG EV7027 Expiration Date: 12/10/2014 Site Address: 0\-�� d��� �fCity/State/ZipNf&WM(� u5 `ach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL a. 152 can lead to the imposition of criminal penalties of a 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 ip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby cerd under the pa' s and penalties of perju y that the information provided above is true and correct iature: �,vt7 ae#: fficial use only. Do not write in this area, to be completed by city or towns official ity or Town: Permit/License # suing Authority(circle one): Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.plumbing ffAspector Other Mact Person: Phone#: Nightwatch Protection, inc. 50A Northwestern Dr.,Suite 9 Salem,NH 03079 Kevin ���� 15 Holly St.,Suite 208 Scarborough,ME 04074 President toll bee(888)722-9282 x121 kg@nightwatchprotection.com www.nightwatchprotection.com Commonwealth of Massachusetts Department of Public Safety Security Systems-S-License License:SS-001606 M1 22 BRURWOOD ' Westford MA NDI j ��J F Commissioner Expiration: 01/25/20 f 6 Fold,Then Detach Along All Perforations t �y OF ` _pI to T%_ ilG 1,If2ltl l '3 f Mt&A l C I ANS ISSUES THE. FOLLOWING L:I CT''NSE AS A Rf C I STERED SYSTEM CONTRACTOR NlOTWATCN PROTECTION INC PAUL J DELSIONOR 22 RR I ARbI'I}OD DR I YE 1 ESTFORD MA o 1886-i i 6; 7024 C 07/31/1-6 50372 SM4KARy OF INSURANCE TilE TFORD FOR: NIGHTWATCH PROTECTION INC Prepared:12/10/2013 50 NORTHWESTERN DR # A UNIT 9 SALEM NH 03079 Phone: FAX: BY: HONE OFFICE PAYCHEX INSURANCE AGENCY INC 210705 PO BOX 33015 SAN ANTONIO TX 78265 Phone: FAX: (888) 443-6112 ACCOUNT POLICY RECAP Policy Number Egg Date_EM Date Premium Workers' Compensation 76 WEG EV7027 12102013 12102014 Hartford Underwriters Ins Co POLICY DETAIL Policy Workers' Compensation Policy States: ME MA NH Location 01 Premises Address 15 HOLLY ST SCARBOROUGH, ME 04074 Location 02 Premises Address 22 BRIARWOOD DR WESTFORD, MA 01886 Location 03 Premises Address 50 NORTHWESTERN DR• # A UNIT 9 SALEM, NH 03079 Worker's Compensation Coverages loyer's Liability_ Limits Limit Disease - Policy Limit $500,000 Disease - Each Employee $100,000 Each Accident $100,000 Individual Included/Excluded Class/Payroll Detail ,- Class Description Class code Payroll Location 01 - ME SALESPERSONS OR COLLECTORS - 8742 $56,243 Location 02 - MA FIRE ALARM, TELEPHONE OR 7601 $80,189 Location 02 - MA SALESPERSONS, COLLECTORS OR 8742 $36,329 Location 03 - NH AUDIO OR INTERCOMMUNICATION 7605 $117, 134 Location 03 - NH SALESPERSONS OR COLLECTORS - 8742 $48,580 Location 03 - NH CLERICAL OFFICE EMPLOYEES NOC 8810 $312,969 'his summary and its attachments provides high level overview of policy coverages and does of include all conditions, limitation or exclusion. Please refer to the actual policy orms for detailed coverages, limits and deductibles. l ® DATE(MM/DD/YYYY) ACOOR o CERTIFICATE OF LIABILITY INSURANCE 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(ies)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 Beecher Carlson Insurance Agency, LLC CONTACT NAME: Beecher Carlson Insurance A enC LLC 1700 Hudson St., Suite 204 PHONE -7 - FAX A/C No: 503-274-0323 Longview, WA 98632 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N www.beechercarlson.com INSURER A: Great Midwest Insurance Company INSURED INSURER B: Great Midwest Insruance Company Nightwatch Protection Inc 50-A Northwestern Drive Suite A INSURER C: Salem NH 03079 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 18016506 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 ADDLITYPE OF INSURANCE INSR WVD SUER POLICY NUMBER MM/DPOLDNYYY POLICY LIMITS LTR A GENERAL LIABILITY PP00036987-01 9/28/2013 9/28/2014 EACH OCCURRENCE $ 1,000,000 v/ COMMERCIAL GENERAL LIABILITY PREMISES Ea RENTED $ 100,000 CLAIMS-MADE 12 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 �/ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED e SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED Pe�PERT DAMAGE $ HIREDAUTOS AUTOS $ B UMBRELLA LIAB ,/ OCCUR CX00000522-01 9/28/2013 9/28/2014 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED Lj RETENTION$ $ WORKERS COMPENSATION WC STATU- O H- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS R ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Security Service Errors&Omissions PP00036987-01 9/28/2013 9/28/2014 1,000,000 each claim/2,000,000 aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover MA 01845 AUTHORIZED REPRESENTATIVE PORT Charles W.Flober ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD CERT NO.: 18016506 Stacy Gonyea 10/10/2013 4:24:06 Pt4 Page 1 of 1