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Home My WebLink AboutWiring Permit - Permits #12158 - 0 FOUNTAIN DRIVE 2/11/2014 ................ Date... . .�.... � °�NCArH'tio TOWN OF NORTH ANDOVER .• o c PERMIT FOR WIRING W.u E ,88ACHU8� i This certifies that...... ....... ............. s ..... n .......................... .................... i t r ! has permission to perform 3 ... ` ..`. x ..,. . ... .. ......... wiring in the building off ..................`� .......} `..... ....... . .. ` ... V t 1 9 i at .... .... € t r North Andover,Mass. tfJia� fee. , a Lic.No. . . ...� �� °�� k......... ......... � �LEG'TRICAL INSPECTQ� 'j Check# 16 ( om wnweahk o f Maedachueetfa Official��U��seOnly c�department of J`cc77 ire Serviced Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 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: 2-10-2014 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) Fountain Drive Owner or Tenant North Andover Housing Authority Telephone No.978-701-6109 Owner's Address 310 Green Street. North Andover MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate 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 Location and Nature of Proposed Electrical Work: Replace existing lighting fixtures with new. 6 -6 unit bldg's (7 fixtures per unit(252 fixtures)) 1 -4 unit bldg (7 fixtures per unit(28 fixtures)) Comm.Bldg=7 fixtures Com letion ofthefiollowing table ma y be waived b y the Inspector o l Aires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 287 Swimming Pool Above ❑ In ❑ o.o Emergency Lighting 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 Tons No.of Alerting Devices 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 Shins 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 ifdesired,or as required by the Inspector of 117ires. Estimated Value of Electrical Work: $76000.00 (When required by municipal policy.) Work to Start: 2-18-2014 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 [X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is tare and complete. FIRM NAME: lem's Electric Company Inc. LIC.NO.: 20457A Licensee: Todd Clemens Signature LIC.NO.: 37846E (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:401-253-4043 Address: 11 Broadeommon Road, Bristol RI 02809 Alt.Tel.No.: *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 ❑o vner"s a"e . Owner/Agent PERMIT FEE: 1000.00 Signature Telephone No. • �,� e 3 J The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.inass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Conti-actors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Clem's Electric Company Inc. Address: 11 Broadcommon Road City/State/Zip: Bristol / R1 /02809 Phone#: 401-253-4043 Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with 15 4. R I am a general contractor and 1 6. E]New construction employees (full and/or part-time).* have hired the sub-contractors 2.E1 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. E] Building addition [No workers' comp. insurance comp. insurance.: required.] 5. E] We are a corporation and its 10.rX Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their II.E] 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.R Other comp. insurance required.] *Any applicant that checks box#I 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 ant an employer•drat is providing workers'comhensatiorr instir(tnce for my employees. Below is thepolicy andjob site information. Insurance Company Name: AmQuard Insurance Company Policy#or Self-ins. Lie. #: CLWC575388 Expiration Date: 1-1-2015 Job Site Address: Fountain Drive 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 oxup 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 hereby certify under thepains andpenalfies ofl)erjury that the infirtnationprovided above is true and correct. Signature: (?Amz�Z�d.- Date: 2-10-2014 Phone#: 401-253-4043 Official use only. Do not write in this area,to be completed by city or toJV11 official. City or Town: Perinit/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 Pei-son: Phone A�n c t A Lot, ,k-fl., I S S u G A klv I AN 4LECTR I C I U. CLCMENS D k CLEMENS C 17 CAS 17 A S I"STO 3 846�1 40; CLEMELE•01 MUAB CERTIFICATE OF LIABILITY INSURANCE DAT1/212DD/YYYY, �----' 1�zi2ola 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 poiicy(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 Ilea of such endorsement(s). PRODUCER NRUT T pX Automatic Data Processing Insurance Agency,Inc Pr�cME: Ex NC No 1 ADP Boulevard E„ Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL B INSURER A:AinGuard Insurance Company INSURED Glenn's Electric Company,Inc. INSURERS: 11 Broadcommon Rd INSURERC: Bristol,RI 02800 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. _ INSRLTR - D 8 BR POLICYNUMBER t�DDmYY MIO.IIDDIMY LTR TYPE OF INSURANCELILfITS GENERAL LIABILITY EACH OCCURRENCE s COMiMERCIAL GENERAL LIABILITY PREMISE$(Ea occurrence) $ CLAIMS-MADE ❑OCCUR LIED EXP(Any one person) S PERSONAL G ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S POLICY JECTLOC $ PRO- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT We accident S ANYAUTO BODILY INJURY(Per person) $ ALLOVIIIED SCHEDULED BODILY INJURY(Pe(accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS _(Per accident S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB . CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X OCSTLAITU• _0TR• AND EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNEPJEXECUTIVE YIN CLWC676388 1/1/2014 11112015 E.L EACH ACCIDENT _ $ 100,06 OFFICERWELiBER EXCLUDED? N I A (Mandatory lnNH) E.L.DISEASE-EA EMPLOYE4 S 100,00 11 yyes describe under DESCRIPTION OF OPERATIONS be'on E.L.DISEASE-POLICY LIMIT I$ 600,00 • DESCRIPTION OF OPERATIONS 1LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If moro 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 COIntrio nwalfh of Massachusetts ACCORDANCE WITH THE POLICY PROVISIONS. City Hail Boston,MA 02222• AUTHORIZED REPRESENTATIVE 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD