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HomeMy WebLinkAboutWiring Permit - Permits #13377 - 6/15/2015 .............. p�ORTh TOWN OF NORTH ANDOV9R � L a PERMIT FOR WIRING 88ACHU �s This certifies that ....... � .. . .: . ..- t has permission to perform .. ....!&In e ..................................................... wiring in the building of.... t at ....: :... .€ $.. E,p , �` North Andover,Mass. .................. s_..�........ Fee ......... . -=�F � ELECTRICAL INSPECTOR Check# r"` t i �7 \MI�w��/fiiMi.��'I^'" V111�i1Y1 V. +Vllly gamin= Permit _- No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/07j eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WC),527 CMR 12.00 (PLEASE PRINT ITV INK OR TYPE ALL INFORMATION) Date: (19664L .. City or Town of: ra o 2.4-�, P*ti&v e...2 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) a 3 t=e-o..+\.)v%e-" A v ti u e Owner or Tenant R.o b&. co +l a Telephone No.q'7 8-"l c�t ' `is Owner's Address Same as above . is this permit in conjunction with a building permit? yes ❑ No Q (Check Appropriate Boa) purpose of Butndmg Dwelling 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: , Completion of the followingtable may be waives'by the inspector of Wires To No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tabs Generators KVA o,o mergency No.of Luminaires Swimming Pool Above ❑ d. ❑ ButterY Units FIRE ALARMS No.of Zones No.of Receptacle Outlets No.of Oil Burners �o on and No,of Switches No.of Gas Burners Initiating Devices. °-W No.of Alerting Devices No.of Ranges No.of Air Cond. TO O eat p umber Tons KW o.of untamed Na of Waste Disposers Totals. Detedion/Ale Devices Mimi • . No.of Dishwashers 1 + Space/Area Heating KW Local❑ Connection El other No,of Dr yers orHeating Appliances KW No,.of Equivalent No.oAo.oil Data Wiring: f H Heater KW No.S Ballasts No. A ivices or uivalent �c � Telecommnnicahons ing: Hydronassage Bathtubs JNo.of Moters Total HP NToe ref 1Aee+i�ces or E trivalent OTSER: Attach additional detail if desires;or as required by the Inspector of Wires. Esdmated Value;V�EGE k: $660.00 (When required by municipal policy.) ons to be requested in accordance with NEC Rule 10,and upon completion.Work to Start: dINSURANCE nless waived by-the owner,no permit for the performance of electrical work may issue unless the licensee provides goof of liability insurance including"completed operation"coverage or its substantial equivalent. The certifies that such coverage is in force,and has wlibited proof of same to the permit issuing office. 'CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (Specify:) n is true and complete I wd fy,hndp..dW pdM•�ppt of perjury;drat the infotmadon on this aPP O FIRM NAME Northeast Electrical Services INC. LIC.NO.:20782A Licensee: Daniel B. Kobus Signature C,NO.:� Bus.TeL No.,508-966-7467 (1fapp�ble,enter"exempt»in the license number line.) -- Address: 40 N.Main Street. P.O Box 361, Bellingham.MA 02019 Alt.Tel.No.: *P.er M.G.L.c..147,s.57-61,security work requires Deparmaent of Public Safety"S" Lic.No. License: 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 ❑Owner's enL Owner/Agent Telephone Na PERMIT FEE:S Signal are "� ,.. � A The Commonwealth of Massachusetts Department of Industrial Accidents tag Office of Investigations 600 Washington Street Boston, MA 02111 U www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name.(13usiness/Organization/lndividual): Northeast Electrical Services Inc. Address: 40 North Main Street,P.O.Box 361 City/State/Zip: Bellingham,MA 02019 Phone #: 508-966-7467 x.307 Are you an employer?Check the appropriate box: Type of project(required): 1.IT I am a employer with 24 4. 01 am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. 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. workers' comp. insurance. 9. [3 Building addition [No workers' comp. insurance 5. El We are a corporation and its 10MElectrical repairs or additions required.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 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 their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: utamatiq Data Porcessing Agency Inc. Policy#or Self-ins, Lic. #: NOWC5295 7 Expiration Date: 7/29/15 C i �d i Job Site Address: City/State/Zip: 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is and correct �Siinature: Date: ane#: 508-966-7467 x. 307 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#: NORTELE-05 MOSA CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 7I25/225/2014 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 N 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 NAME: Automatic Data Processing Insurance Agency,Inc PHONE FAX 1 ADP Boulevard AIC No Ext: A/C No: E-MAIL Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:AmGuard Insurance Company INSURED Northeast Electrical Services INSURERB: 56 Pine Ridge Drive INSURER C: Franklin, MA 02038 INSURER D: 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, INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE DOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO-- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMIT ER A ANY PROPRIETOR/PARTNERIEXECUTIVE NOWC529567 7/29/2014 7/29/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? 1-1 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 S 1,000,00 DESCRIPTION OF OPERATIONS 1 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ACC> 9/29 CERTIFICATE OF LIABILITY INSURANCE DATE(/2014 MMIDDIYYYY �� 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 Gretchen Houghton NAME: g QUINCY INSURANCE AGENCY, INC. PHONE . (781)431-9600 AAC No:("1)431-9595 144 Gou"ld Street E-MAIL .ghougton@quincyinsurance.net Suite 152 INSURERS AFFORDING COVERAGE NAIC# Needham MA 02494-2337 INSURER A:Harle soil-le Insurance Company 3582 INSURED INSURERB:Safety Insurance Group 9454 Northeast Electrical Service, Inc. INSURERC: PO Box 361 INSURER D: INSURER E: Bellingham MA 02019 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1472504784 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. ILTR EXP TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIPOLDDYfYYYY EFF MM/DDY/YYYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE _$ 2,000,000 DAMAGE To RENTED 50 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE Fx_1 OCCUR SPP00000048041T 6/25/2014 6/25/2015 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY PRO- LOC $ A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ 1, 00,000 ANY AUTO BODILY INJURY(Per person) $ B ALLOWNED SCHEDULED 5059113 6/25/2014 6/25/2015 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS M NON-OWNED Pe�acEcIdentDAMAGE $ X PIP-Basic $ 8,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ 0 1 PSOOO00066725T 6/25/2014 6/25/2015 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Rebecca Ness/RMN ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS026(201005).01 The ACORD name and logo are registered marks of ACORD �i.,ti (�l'�'i� i x ';� ,1 fkt�`,4 i y •1yyzt ��t•15 S 'S' 17fFF� ;y r+.'N '4 f. All ; yy �30J