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HomeMy WebLinkAboutWiring Permit - Permits #12686-1 - 9/16/2015 Date......�..l.�.�t.,.�. ........... Y pOR7l� �� •T"�, tiooL TOWN OF.NORTH ANDOVER ° m PERMIT FOR WIRING B�CHUg� This certifies that ........ ....................... R.. has permission to perform a......... ... ....... �............................. . ...... . ...:. wiring in the building of ...., ., ........................................ .............................. at ...... ... .... ...... .......... �<a �: '.... North Andover,Mass. Fee....' . ®....Lic.No. ( .................................................................................... ELECTRICAL INSPECTOR Check# Commonweafth of Wassachusetts official Use Only Permit No. Departmen t of Eire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/091 (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 ININK OR TYPE ALL INFORIIATION) Date: 9/9/15 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. N,j Location (Street& Number) 85H Flagship Drive Owner or Tenant Cal-Pali Telephone No. ww Owner's Address "same" '4, Is this permit in conjunction with a building permit? Yes Ej No H (Check Appropriate Box) Purpose of Building Office-Commercial 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 Arnpacity Location and Nature of Proposed Electrical Work: Replace 2x2 light fixtures to LED "I Completion of thefolloiving table inqj,be iraireet by the Inspector of Tvires. No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lurninaire Outlets No.of Hot Tubs Generators KVA J No. of Luminaires 50 Swimming Pool Above I No.of Emergency Lighting ❑ El y grnd. El grnd. Batter 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. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Purnp N.!!!!u............. Tons KW No.of Self-Contained........... ........... Totals: I. I. I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local E] Municipal F-1 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. Hydrornassage 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 ffires. Estimated Value of Electrical Work: $9000.00 (When required by municipal policy.) Work to Start: 8/19/2015 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 pro- vides 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 0 130ND n OTHER F1 (Specify:) I certify,under the pains arm penalties oj'j)eijuiy,that the inja•tnafion on this application is true and complete. FIRM NAME: Facilico,Inc LIC. NO.: A]7545 Licensee: Bryan Regan Signature LIC. NO.: E36113 (1j'applicab1c,enter "exempt"in the license number line.) Bus.Tel. No.: 866-929-2100 Address: 10 Walnut Hill Park Woburn,MA 01801 Aft.Tel. No.: 617-201-4373 *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)F-1 owner 1:1 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ A") I . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 IN www.mass.,aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Natne(Business/Organization/Individual): Faeilico, Inc. Address: 10 Walnut Hill Park City/State/Zip: Woburn, MA 01801-6823 Phone#: 866-929-2100 Are you an employer? Check the appropriate box: 1. ® I am an employer with 12 4.❑I am a general contractor and Type of Project(required): employees(full and/or part-time).* I have hired the sub-contractors 6. ❑New Construction 2. proprietor or ro sole a am I listed on the attached sheet. ❑ P p 7. El Remodeling partnership and have no employees These sub-contractors have working for the in any capacity. employees and have workers' g• ❑ Demolition [No workers' comp. insurance comp. insurance. $ 9. ❑ Building Addition required.] 5.❑We are a corporation and its 10.© Electrical Repairs or Additions 3.❑ I am a homeowner doing all the officers have exercised their work myself. [No workers' comp. right of exemption per MGL c. 11.❑ Plumbing Repairs or Additions insurance required.]� 152,A 1 (4), and we have no 12.❑Roof Repairs employees. [No workers' comp. 13.❑Other 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 work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attach 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 attt an employer that is providing workers'cofupeitsation insurance for ttty employees. Below is the policy and job site information. Insurance Company Name: St. Paul Travelers Policy#or Self-ins. Lic.#: IEUB 87K 735 5316 Expiration Date: 5/6/16 Job Site Address: 85H Flagship Drive City/State/Zip: N. Andover,MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and e_ypiration(late). 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 and penalties of perjury that the information provided above is true and correct. Signature: 13rga4mv M. Regawv Date 9/9/15 Phone#: 866-929-2100 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#: 7 ® DATE(MMIDDIYYYY) A�V CERTIFICATE OF LIABILITY INSURANCE 5/13/2015 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 CONTACT Corinne Rescigno Tarpey Insurance Group PHONE o E t (781)246-2677 X NOV. (781)224-0973 442 Water St E-MAILs:corinne@tarpeyinsurance.com PO BOX 567 INSURERS AFFORDING COVERAGE NAIC# Wakefield MA 01880-4667 INSURERA:Travelers indemnity of America 25666 INSURED INSURERB:Travelers Indemnity Company 25658 Facilico Inc. INSURERC:Travelers indemnity Cc of Conn 25682 10 Walnut Hill Park INSURER D: INSURER E: Woburn MA 01801 INSURER F: COVERAGES CERTIFICATE NUMBER:2015-16 Liab 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 ADDLITYPE OF INSURANCE INS.SWVD UER POLICY NUMBER MMIDDIYYYY MM/DDIYYYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN D A CLAIMS-MADE ❑X OCCUR PREMISES Ea occu ence $ 300,000 680-35F65886-15 5/6/2015 5/6/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X JECT LOC 2,000,000 POLICY PRO OTHER: I CNTBL $ AUTOMOBILE LIABILITY Ea acccl ideD SINGLE LIMIT $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED rX SCHEDULED Bp,-9514H796-15 5/6/2015 5/6/2016 BODILYINJURY(Peraccident) $ AUTOS AUTOSNON-OWNED PROPERTY DAMAGE $ XHIREDAUTOS AUTOS APer accident Uninsured motorist BI split limit $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAR I CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION 5 000 CUP-4172YO90-15 5/6/2015 5/6/2016 $ WORKERS COMPENSATION S STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ .1 000 000 N/A OFFICER/MEMBER EXCLUDED? C (Mandatory in NH) IEUB87K7355315 5/6/2015 5/6/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St ACCORDANCE WITH THE POLICY PROVISIONS. N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE M Tarpey,CPCU,CIC,AAI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 1201401� l ONIMONWEALTH OF=MS USEZ ACHTTS SOMt O 3' I EUECTF�1-C 1 ANS. ��rya .= 1 SSUE� NIr FOLLOWI NO:::: tl CECfSE A F1 JOURNEYM41�F ELEGTR 1 G I Ail °` IF REGAN ,. � 1R.lOTCIRCLE, LD Mk 018$0 1$63Mll f l d x 1,7 REG z n 39op5 9 i