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HomeMy WebLinkAboutWiring Permit - Permits #12179 - 0 FOULDS TERRACE 2/20/2014 f Date �:......ze ... .......... Of NOR7�y q� ,a .• TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 88gCHUg�4 i t f This certifies that .......................................................... 3 ha s permission to perform ,...:....6.` .,..,- i ,` E ` o Pa .... wiring in the building of...i ....f.... ..... . ........ ........ ` ..... . . a c at ... :. North Andover,Mass. E� a Fee . Lic.No I ....................... ELEOfzicALINSPECTOR U` Check# `- EE; f 4 (foomwnwea&ol kaijac4wettj 2epartownt of ire S Official Use Only ePldW Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/17] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMIZ 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2-19-2014 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) Foulds Terrace Owner or Tenant North Andover Housing Authority Telephone No. 978-682-3932 Owner's Address One Morkeski Meadows, North Andover MA 01845 Is this permit in conjunction with a building permit? Yes F-1 No FX1 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF-1 UndgrdF1 No.of Meters New Service Amps Volts Overljead❑ UndgrdF-1 No.of Meters Number of Feeders and Ampacity Location and Nature of Propose(]Electrical Work: Replace existing interior common area, Exterior&tennant lighting fixtures with new. (3 fixtures per unit) 3-10 unit bldgs&2-11 unit bldgs.Total Units=52 plus community area Conipletion of thefiolloif,ing table ingy be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 288 Swimming Pool Above El 1"- 0 No.of Emergency Lighting grnd. grind. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.ofZones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. TotalTons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons I-(W No.of Self-Contained Totals: ............. Detection/Alerting Devices F� No.of Dishwashers Space/Area Heating KW Local Connectio Municipal n ❑F-] 0 ther No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring No.of Devices or Eq uivaient OTHER: Attach additional detail if desired,or cis required by the Inspector of Wires. Estimated Value of Electrical Work: 77,000.00 (When required by municipal policy.) Work to Start: 2-20-2014 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 [)j BOND F-1 OTHER n (Specify:) I certify,under the pains and penalties ofperjut:v,that the information on this application is true and complete. FIRM NAME: Clem's Electric Company Inc LIC.NO.: 20457A Licensee: Todd Clemens Signatur LIC.NO.:37846E (If applicable,enter "exel n in the license number line.) Bus.Tel.No.:401-253-4043 Address: 11 Broaacommon Roari, Bristol, R1 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 E]owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Lk The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 wwminass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/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. E] I am a general contractor and 1 6. R New Construction employees (full and/or part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. r_1 Remodeling ship and have no employees These sub-contractors have 8. E] Demolition working for me in any capacity, employees and have workers' 9. R Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. We are a corporation and its IO.FXElectrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their I I.R 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 lJorneovners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name ofthe 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. lain an employer that is providing workers'compensation insurance for iny employees. Below is the policy and job site information. Insurance Company Name: Am-guard Insurance Company — Policy#or Self-ins. Lic. #: CLWC575388 Expiration Date: 1-1-2015 Job Site Address: Foulds Terrace City/State/Zip:North Andover/MA/01 845 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 coverage verification. I do hereby certify under the pains andpenalties of perjury that the informationprovided above is true and correct. Signature: _�;W6 14Y(?AM,4u Date: 2-19-2014 Phone#: 401-253-4043 Official use only. Do not write in this area,to be completed by city or toivit 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 G.Other Contact Person: Phone#: �i ®® //11 A'y' /� /� CLEMELE-0[ MUAB /��®��e CERTIF�CA 1 ®F L'/°i BILITY INSURANC DAT1/21d/DD/9Y1'Y) � 1>•21ao1q 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(toes not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Not E: T Automatic Data Processing Insurance Agency,Inc Hm a - Nc: 1 ADP Boulevard "! �i Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:AmGI(ard Insurance Company INSURED Clorn's Electric Company,Inc. INSURER a: 11 Broadcommon Rd INSURERC: _ Bristol,R1 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 PAY 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. LTR TYPE OF INSURANCE DD S BR F 0I YP YPOLICYNUMBER MOIDDY MOD LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY _PREMISES(Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPJOPAGO $ pOUCyFj PRO-JECTLOC $ AUTOMOBILE LIABILITY COJdBINEO SINGLE L11.1R Ee ecctdent $ _.. ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNEO PROPERTY DAMAGE $ AUTOS _(Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAa CLAIMS•IJADE AGGREGATE $ DEC) I I RETENTION$ $ WORKERS COMPENSATION X WCST'TUSR�__ AND EMPLOYERS'LIABILITY A ANY PROPRIETORIPART14EIVEXECUTIVE YIN CLWC676388 1/1/2014 1I112016 E.L.EACH ACCIDENT $ 100,00 OFFICERR.IEI.MSER EXCLUDED? ID NIA ------ (Mandatory In NH) E.L.DISEASE•EA EMPLOYE $ 100,000 nVes describe under SGrRIPT ION OF OPERATIONS be'ow E.L.DISEASE•POLICY LIMIT 6 600,000 DESCRIPTION OF OPERATIONS ILOCATIONSJVEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Commonwalth of Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Hail Boston,MA 02222- AUTHORIZED REPRESENTATIVE 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010106) The ACORD name and logo are registered marks of ACORD k1--- - CERTIFICATE OF LIABILITY,INSURANCE ..I__.4/2/201.'3 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 poiley(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,cortain policies may require an endorsement. A statomont on this certificate does not confer rights to tho certificate holder III lieu of such ondorsomont(s). PRODUCER CAONETACT Donna Rodrigues, CIC, CRIS John Andrade Insurance Agency, Inc. P110FJu (401)253-6542 FAX (401)2534070 559 }lope Street AE ,Is •drodrigues@johnandradoinsurance.com INSURERS AFFORDING COVERAGE HAIL 0 Bristol RI 02809 INSURERA:Selective of South Carolina 19259 INSURED INSURER B: CLMS ELECTRIC CO INC INSURERC: 11 BROADCOMMON RD INSURER D: INSURER E: BRISTOL RI 02009-2758 INSURER F: COVERAGES CERTIFICATE NUMBER CL133413086 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. IAWL SUUK LTR TYPE OF INSURANCE I S Y POLICY NUMBER PO DDY PU UU/YYXYPY UNITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X CO.MMERC1AL GENERAL LIABILITY PRE tl ES Ea occurrencel $ 100,000 A ClAIL1S-I.IADE Ex—]OCCUR 1693991 /26/2013 /26/2014 MED EXP(Any one person) S 10,000 PERSONAL G ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 OEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMP/OPAGG $ 3,000,000 j X POUCY M PRO- LOC S AUTOMOBILE LIABILITY CO?dBINEB SINGLE Ut.:IT E, S 11000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALLO'ANEO SCHEOULED 1693991 /26/2013 /26/2014 BODILY INJURY(Per accident) $ • AUTOS AUTOS NON-O•ANEO PROPERTY DAI.IAGE $ HIREDAUTOS AUTOS Per acc:do UNnsuredmotodstcombtned $ 1,000,000 X UMBRELLA LIAD OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAD CLAIMS-BLADE AGGREGATE S 3,000 i 000 DEB I I RETENTION 1693991 ./26/2013 /26/2014 S WORKERS COMPENSATION WCSTATU• OTH• AND EMPLOYERS•LIABILITY Y I N ANY PROPRIETORIPARTNERJEXECUTIVE E.L.EACH ACCIDENT $ OFFICERLRIEMBER EXCLUDE( NIA (hisodalory In NH) E.L.DISEASE•EA EMPLOYEE $ Ifyes desedbounder DESCRIPTION OF OPERATIONS belerr E.L.DISEASE•POLICY LILiIT S A Contractors Equipment 3 1693991 ./26/2013 /26/2014 $75,000 any/al leas^_d or rented egvpmenl DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE C o mm o nw a l t h of Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE-DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Hall AUTHORIZED REPRESENTATIVE Boston, MA 02222 Mark 1•latrone, CIC/SID ACORD 25(2010105) ©1988.2010 ACORD CORPORATION. All rights reserved. INS0960nlmmm T1.o Ar:r1Rh namn nnrl Innn ara roniefo.nrl'anarba of Ar:.rlt7(1 40 S�Ut 4A 0 I I G VINE �RE At D 0 J.'L E CTR I C I D,,,gh CLEMENS gf CLEMENS 17 CAS CASYt 17 CA StOw 0 2 4 5 7j, 1 02809-45, 1 4411869 kl$