The URL can be used to link to this page

Home My WebLink About- Permits #12435 - 105 HILLSIDE ROAD 6/9/2014 f ..kth.� ...................... � {JORT{e ' o,►r°•'� -.: ;'. oo� TOWN OF NORTH ANDOVER p d PERMIT FOR t' ° WIRING 8saCHU This r certifies that � e ' � c has permission to perform V�f ... Q;n t .t...�. wrong in the ng° building .......................................................... at ' � . North Andover,Mass Fee r. No, t Check# crtucnL INSPECTOR / � A =t Official Use Only Commonwealth of Massachusetts VI) " Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Date Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK n 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: June 2, 2014 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) 105 Hillside Road Map: Lot: Owner or Tenant Donald&Kathleen Gregoire Telephone No. 978-479-4968 01 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps —Volts OverheadE] Undgrd ❑ No. of Meters New Service Amps Volts Overhead [_1 Undgrd El No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Remove meter to allow for siding installation Completion of the following table inay be waived by the Inspector of Fires. 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 Above Ei In f Emergency Lighting No.of Lighting Fixtures Swimming Pool ❑ E] 3 grnd. grild. Battery Units <❑ :�� Na,of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump INy!pyer Tons.......... llcwl No.of Self-Contained Totals. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal F-1 Other Connection No.of Dryers Heating Appliances I(W Security Systems: No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters ITVSigns Ballasts No.of Devices or Equivalent Ip No.Hydromassa2e Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: tNl Attach additional detail if desired, or cis required by the h7spector of Wires. Estimated Value of Electrical Work $400.00 (When required by municipal policy.) Work to Start: 6/7/14 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the erformance of electrical work may issue unless the licen- see it �r the c c see provides proof of liability insurance including"completed operation" rage or its substantial equivalent. The undersigned certifies t P 1. 1 issuing that such coverage is in force, and has exhibited proof of same to the per i i uing office. ❑ Spc. Y. CHECK ONE: INSURANCE 15� BOND F Spec' y:OTHER I certify,under the pains and penalties of perjury,that the inforin im o III application is true and complete. FIRM NAME: Andover Electric Services, Inc LIC. NO.: 14302 Licensee: Robert J. Branca - Signatu ZZ LIC. NO.: *Per M.G.L. c. 147,s. 57-61,security work requires Department ofK11blic.Safety"S"License: LIC.NO.: S: (If applicable, enter "exempt"in the license member line.) Bus. Tel.No.: 978-475-4995 Address: 19 Dale St, Andover, MA Zip: 01810 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 by law. By my signature below, I hereby waive this requirement. I am the(check one)D owner El owner's agent. Permit Fee: $55.00 ❑ Owner/Agent Signature Phone: DIVISION OF PROFESSIONAL LICENSURE��.\`��.�z , ti C ai rl �s 4'1�1 'd'''� '� �•:y. Y��J3lt�("�� V ¢k�-h'>t IaF Axe ,'I-ye� v iAr4Jn Q 'vk�, �t kepi `.. ,ilyi I•?L � g'� ,��'�.i�1.�,� -t�"nil'��'�s�' U?r t � A- ��c" � _}3LICENSE,NUMBER EXPiRATION DATE; SERIAL NUN1BER i'f°r`{.� �Tai':�`,.�i�litf'..S.�.t.�;�..�r,��.�f�: �`+,.�` ,:�.1,�" a ...cryif��a t.,..:Z..��.t��..:✓..�?.ci.. ` ' t�11Y1SION OF 1'ROF£SSIUNIAL LlCEN3URE•n'"N�- "l"12,��4 , 6v,%L% �J- VIM { 11 B 1 LICENSE NUMBER.` 'r EXPIRATION DATE' S5 IAL"NU _ .' 1t '� The fnmmn»wealth of 114Ta, ru.cettc Office of Investigations d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly 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.Q I am a employer with 5 4. n 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 g. Demolition workingfor me in an capacity. employees and have workers' Y p tY• 9. F1 Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 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:4/28/15 Job Site Address: 105 Hillside Road City/State/Zip: No 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 we civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be adv' th a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cover verific ion. I do hereby certify under the pains a penalties o perjury that the information provided above is true and correct. Si nature: Date: June 3, 2014 Phone#: 978-475 5 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 Cleric 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: O 1J a DATE ( lY)., AL- L`... R CERTIFICATE OF LIABILITY INSURANCE 06/03/20143/2014 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 phone: (970)474-0810 Fax: (970)474-0890 NAME: Samel Insurance Agency,Inc. JONATHAN M SAMEL CIC LIA PHONE FAX SAMEL INSURANCE AGENCY,INC. vc No EA): 978 474-0810 ac Na: 978 474-0890 E-MAIL info@samel-ins.com 15 CENTRAL STREET AODREss: ANDOVER MA 01810 PRODUCER 1254 CUSTOMER ID: INSURER(S) AFFORDING COVERAGE NAIC# INSURED ANDOVER ELECTRIC SERVICES INC INSURERA Sentinel Insurance Co,LTD 11000 PO BOX 629 INSURERS :Citation Insurance Company 40274 ANDOVER MA 01810 INSURER :Sentinel insurance Co,LTD 1100 INSURERD: Hartford Fire Insurance Company 19682 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 39512 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 ADD'L SUBR EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDYIYYYY MM/DD EFF YmvY LIMITS A GENERAL LIABILITY 08SBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS-MADE I X IOCCUR PREMISES Eaoccurence $ 1,000,000 MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,060 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 _POLICY X PR0 LOC + B AUTOMDBILE LIABILITY Y COMBINED SINGLE LIMIT KW7918 03/23/14 03/23/15 CO CO ANY AUTO accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ C X UMBRELLA LIAB X OCCUR 08SBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE 2,000,000 Excess LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DEDUCTIBLE X RETENTION $ 10,000 $ D WORKERS COMPENSATION Y/N 08WECCM5940 04/28/14 04/28/15 X ORYTLIMITS OTH $ AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER[EXECUTIVE E.L.EACH ACCIDENT 500,000 OFFICERIMEMBER EXCLUDED? N] N/A $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 500 000 If yes,describe under $ r DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Operations typical to commercial and residential electrical contractor. CERTIFICATE HOLDER CANCELLATION Hi-Tech Window&Siding Installations,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 29 Arrow Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Methuen,Ma 01844 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: Jonathan Jonathan M.Samel ACORD 25(2009/09) @ 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD