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HomeMy WebLinkAboutWiring permit - Correspondence - 420 GREAT POND ROAD 10/13/2015 j Date [t I i p NoarN TOWN OF NORTH ANDOVER o PERMIT FOR WIRING CHU5 i This certifies that ....... �, tY has permission to perform fmrz ..... LFFee Ig in the building of �� t� — L, at j No �Andover, ....... ........ � Mass. ....... .......Lie.No. ErEciRicni INSPECTORk# Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. i a BOARD OF FIRE PREVENTION REGULATIONS Date Issued: r` APPLICATION FOR PERMIT TO PERFORM•ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(I4IEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: October L 20 T5 City or Town of: ' NORTH 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) Blue Ridge Map: Lot: Owner or Tenant Water Treatment Telephone No. Owner's Address #6 Blue Ridge area(off Salem Street) Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Water Treatment 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: Emergency electrical repair.Remove and replace existing panel, due to water damage COMPletion qfthefollowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA ' No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above El In- ❑ o.o mergency ig tmg rnd. grnd., Battery 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 No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons.......... KW No.of Self-Contained . . ..... ...... ..... ....................... Totals: ...... Detection/Alerting 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 KW 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 Wires. Estimated Value of Electrical Work $3,800.00 (When required by municipal policy.) Work to Start: 10/7/15 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 licen- see 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 o t plication is true and complete. FIRM NAME: Andover Electric Services Inc LIC.NO.: 14302 Licensee: Robert J. Branca Signa e _ LIC.NO.: *Per M.G.L. c. 147,s.57-61,security work requires artme f is Safety'IS"License: LIC.NO.: S: (Ifapplicable, enter "exempt"in the license number line) Bus.Tel.No.: 978-475-4995 Address: 19 Dale St,Andover, MA Zia: A810 Alt.Tel.No.: 978-423-8350 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent, [—Permit Fee: Owner/Agent Signature Phone: co pR • CERTIFICATE OF LIABILITY INSURANCE DATE 0 4/2912 IYYYY) /20(MMID 01 5 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 endoreement(s). PRODUCER Phone: (978)474-0810 Fax: (978)474-0890 CONTACT Samel Insurance Agency,Inc. JONATHAN M SAMEL CIC LIA PHONE 978-474-0810 FA'I 978.474-0890 e e. SAMEL INSURANCE AGENCY,INC. E Lail info@samei-ins.com 15 CENTRAL STREET PRODUCER 12r� ANDOVER MA 01810 mR Q. INSURER 8 AFFORDING COVERAGE NAIC INSURED INSURERA Sentinel Insurance Co,LTD 11000 ANDOVER ELECTRIC SERVICES INC INSURERS :Citation insurance Company 40274 PO BOX 629 ANDOVER MA 01810 INsuRERc :Sentinel Insurance Co,LTD 1100 INSURER D: Hartford Fire Insurance Company 19682 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 42147 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, INSR TYPE OF INSURANCE INSR SUER POLICY NUMBER POLICYEFF POLICYDI EXP LIMITS LT WVD A GENERAL LIABILITY OBSBAIL4326 03123/15 03/23/16 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENER'AL�LIABILITY PREMISES Me ocourencel RENTED $ 1,000,000 CLAIMS-MADE I X I OCCUR MED.EXP(Any one person) $ 10,000 IF— PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 4,000,000 POLICY X PRO- RO LOC $ B AUTOMOBILE LIABILITY KW7918 03/23/15 03/23/16 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS Per accident X NON-OWNED AUTOS C X UMBRELLA LIAB X OCCUR 08SBAIL4326 03/23/15 03/23/16 EACH OCCURRENCE _ 2,000,000 EXCESS LIAa CLAIMS-MADE AGGREGATE 2,000,000 DEDUCTIBLE X RETENTION $ 10,000 $ D WORKERS COMPENSATION OBWECCM5940 04/28/16 04/28/16 X T y A11Ts OTH $ AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT _ SOO,000 OFFICERIMEMBER EXCLUDED? n N/A E.L.DISEASE-EA EMPLOYEE 500,000 - (Mandatory In NH) H yes,describe under E.L.DISEASE-POLICY LIMIT 500 000 DESCRIPTION OF OPERATIONS below $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Operations typical to commercial and residential electrical contractor. CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Attention: Jonathan M.Samei ACORD 25(2009/09) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrialAccidents u Office of Investigations I Congress Street, Suite 100 �7 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Andover Electric Services, Inc. Address: 19 Dales Street City/State/Zip:Andover, MA 01810 Phone#:978-475-4995 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 5 4. I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached.sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity.. employees and have workers' 9. ❑Building addition [No workers' comp..insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself o workers comp. right of exemption per MGL y � ' P 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *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:The Hartford Policy#or Self-ins. Lic. #:08 WEC CM5940 Expiration Date:4/28/16 Job Site Address: 6 Blue Ridge City/State/Zip:North 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 coveW verification. I do hereby certify under thepains wl pe alties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: 978-475 95 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#: FoK Then DeWch Along AN Perforations IN WWI 17 3�#fy7 r�a A � � Ned �'`✓� -�-izxr�tr 4P,y�i n�.,� r 1 . 'T�i; r .-�> rr3lyrJ "rid Fold,Then Detach AJong All Parforations t QELOw11" L3CEN� : E CTR 1 E 1 Ah;s y fiYs i r s Z sf c v �`. 2 ._ ..__ e.. Mi- STATE OF NEW HAMPSHIRE - ELECTRICIA"S BOARD NAME: R0 %RU 8 , EXPIRES:. l u Y