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HomeMy WebLinkAbout- Permits #12670-1 - 1 HIGH STREET 9/14/2015 Date.... ......... NoRrH TOWN OF NORTH ANDOVER ° n PERMIT FOR WIRING * At ,88ACHU5�4 (� 9 This certifies that ... a has permission to perform .. �°ea�•4, ...............................................Ps ........... wiring in the building of... L- at .. . ....... ........................... North Andover,Mass. Fee.. ........ ...... Lic.No ....:. .. � . ......................... � ELECTRICAL INSPECTOR Check# � � (flininoniveafilt ol MamacItuielb Official,Use Only Permit No.❑ V119 2epartment ol3ire Servicej Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (1,,v,blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cocle(N/1EC),1527/,N1R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORA11"I TJOIV) Date: City orTown of: 4,k Avlo vv,r To the In )ectoi-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 6 6 — Telephone No. Owner's Address 17 J 02 101) S�M"+ bt i'j-e- i00 Is this permit in conjunction with a building permit? Yes 1Z No ❑ (Check Appropriate Box) Purpose of Building_ c')/w/0 Utility Authorization No. Existing Service Amps Volts Overhead ❑ undgrd❑ No.of Meters New Service Amps Volts Overhead El undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Complelion of 1he.f6flowing lable inc(l)be waived by the lnsl?ectol•of 1,11ires. No. of No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Trans Total formers I(VA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above -N—o.ot Emergency Lighting No.of Luminaires Swimming Pool EJ I"- El grild. rild. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. TonsTotal No.of Alerting Devices Heat Pump Nuu:14e1*.,. Ioq� KW No.of Self-Contained No.of Waste Disposers ......... ..... Totals: IJ I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal E] Other Connection No.of Dryers Heating Appliances K Security Systems:* W No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or-Equivalent No.Hydromassav_e Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: I No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector.of 11"ires. 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 uni the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. "Frie undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEEI BOND ❑ OTHER El (Specify:) I certify,,under the pains and penalties oj, that the infin-ination on this application is true and complete. FIRM NAME: AAI(kl)e, LIC.NO.: Licensee: -5117119btell Signature LIC.NO.: ;Z,0,A)E Alt.Tel.No.: (Ifapplicable,enter "exenipt"in the license number line.) Bus.Tel.No.: Address: /00 lw�le-�P�kr "vw-r /V?6,7 Q,2&V' *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)11 owner 0 owner's a e t. Owner/Agent Signature Telephone No. FEE: C% 4 Xhe Commonwealth of f'A ass chusetis z . Department of IndlustrialAccidents Z Congress Sheet,Suite 100 Boston,MA 02114 2017 www.mass.go-v/dra I^i :•Sy` Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH TM PFRIMTTJNG AUTHORITY. Applicant Information / a Pleas it Please Print Leg Name(Business/Oxganization/fndividual): /1/ I .Address: ko City/State/Zip: m+ Phone Areyo an employer?Cheektlieappioprlatebox: `type of project()Vequired): Qdl m a employer with : employees(full and/or part-time).* 7. New construction 2. 1 am a sole proprietor or partnership and have no employees Working for me in &. n xelnodelhig any capacity.[No workers'comp.insurance required.] 9. WDemolition 3.n 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[]Building addition 4.nI am a homeowner and will be hiring contractors to conduct all work on my property. 1-will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions 5.❑1 am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insruance.� 6.n We are a corporation and its of gers have exercised their right of exemption perMGL c. 14.[]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] r; • *Any applicant that checks box#1 must also-fill out the section below showing their workers'compensation policy information. i 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 irumber. f am an employer that is pfdviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name; n Policy#or Self-ins,Lic.#: A M✓�i� 6U l ' Expiration Date: � �r fob Site Address: �/ City/State/Zip: yd_-a IqV Attach a copy of the workers'c . pensation'policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e.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 hereby certify under the pains andpenalti o,fp rjury that the information provided ovided move i true d correct. Signature: Date: s Phone# /r(- 311 - 2727 Official use only. Do not write in this area,to be completed by city or town official. City or Town: )?ermit/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#: I Please visait ow ;.0I� site at_ http://www.mass ,gov/dpI/boards/EI. NARDONE ELECTRICAL CORPORATION STEPHEN J NARDONE (EL) 100 WINCH[.S'FER STREET MEDFORD MA 02155-6451 Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS.. BOARD OF EL :CTR`ICIANS ISSUES THE FOLLOWING LICENSE AS REGISTERED MASTER ELECTRICIAN 'S Z NARDONE ELECTRICAL :Lu STEPHEN J NARDONEi ' 100 WINCHESTER STREET` J MI~DFORD MA 02155-6451 11691 A 07/31/16 81221 e i 'Please visit o+.1i v,!ela site at http://www.mass .gov/dpI/boards/EL STEPHEN J NARDONE (EL) 100 WINCHESTER STREET MEDFORD MA 02155-6451 Fold,Then Detach Along All Perforations �,v. COMMONWEALTH OF MASSACHUSETTS QOARb OF El E CTF ICI ANS ISSUES THE FOLLOW ING 'L'tCENSE AS A REG JOURNEYMAN ILECTRICIA 'z STEPH:EN J NARDONE .� 100 WINCHESTER STREET 'U J MEDFORD rin 02155-645`1 25390 E ' 07/31/16 81222 trllentw 'IUUU4Yb NAKUUtLC9 ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/29/2014 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(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 NAMEACT Kathy Wagner USI Insurance Solutions, LLC A N,Ext:413-750-4222 A No): 610-537-9481 123 Interstate Drive EMAIL kathy.wagner@usi.biz g ner West Springfield,MA 01089-3600 ADDRESS: ywaINSURER(S)AFFORDING COVERAGE NAIC# 855 874.0123 INSURER A:ABC Mass Workers Comp SIG 99999 INSURED INSURERS: Nardone Electrical Corporation INSURERC: 100 Winchester Street Medford,MA 02155 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. LTRR TYPE OF INSURANCE NSRADDLSUBR WVD POLICY NUMBER MMIDDY� MM/DID�YY LIMITS GENERAL LIABILITY EACH OCCURRE NCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea oNcccu ence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY[71 PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident E 1 $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION ABCMA00104815 1/01/2015 01/01/2016 X WOCSTATUS OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $1 000 000 OFFICER/MEMBER EXCLUDED? IN N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of MA Workers'Compensation Coverage CERTIFICATE HOLDER CANCELLATION North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 124 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD 0 DATE AC� �- CERTIFICATE OF LIABILITY INSURANCE 12/2/2014 THI6 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 CONTACT Michael Bonacorso NAME: Bonacorso Insurance Agency, Inc. PHONE (781)937-3200 FAX No): (781)937-3202 10 Cedar Street EMAILAppgEss.michael@bonacorsoins.com Unit # 32 INSURERS AFFORDING COVERAGE NAIC# Woburn MA 01801 INSURERA:Travelers Indemnity Co. 25658 INSURED ID 613875 INSURER B:Travelers Property Casualty Co. Nardone Electrical Corporation INSURER C: 100 Winchester Street INSURERD: INSURER E: Medford MA 02155 INSURER F: COVERAGES CERTIFICATE NUMBER:14-15 MASTER 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMILDDY/YYYY MMIDDIIYY Y LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE Fx-1 OCCUR T-CO-1063P565-IND-14 0/31/2014 0/31/2015 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 X CONTRACTUAL, LIABILITY GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COJFCT MBINED SINGLE LIMIT Ea accident) 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED T-810-1070P833-Cor-14 0/31/2014 0/31/2015 BODILY INJURY(Per accident) $ AUTOX HIRED S AUTOS AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DIED X I RETENTION$ 10,00 TSM-CUP-171BP630-TIL-14 0/31/2014 0/31/2015 $ B WORKERS COMPENSATION X WC STATLIMU- OTH- DRYAND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1 OOO 000 OFFICER/MEMBER EXCLUDED? N NIA TNUH8D09394614 0/31/2014 0/31/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Leased/Rented Equipment T-CO-1063P565-IND-14 0/31/2019 0/31/2015 LIMIT $250,000 DESCRIPTION OF OPERATIONS I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS, 124 MAIN ST. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE Michael J. Bonacorso ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. I td Rn9R,,)n4nng�n, 71— AnnOr1..n. and 1 —.1—nF A/+nOr1