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HomeMy WebLinkAboutWiring Permit - Permits #12962 - 207 FARNUM STREET 12/4/2014 i _ Date,.. ....:....... .................... TOWN OF NORTH ANDOVER Sir e_ _�� •• O ° 9 PERMIT FOR WIRING 88ACHU5� s This certifies that ..�.. ".. .................................. .......... ° .. r � ..........................................r "� permission ermission to perform . ................. . g..�... i ! era wiringin the building of...... ........................................................................................................ ....`.......... ,,North Andover,Mass. Fee.. .. .Lic.No . �?....... �...... ..: .....A. ... ELECTRICAL INSPECTOR V Check# y G _ I i i Ott: Official Use Only sp of tins�srvres9 Permit No. A(, BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT To PERFORM ELECTRICAL WORK All work to be Performed in accordance with the Massachusetts Electrical Co�(W c,�27 CMR 12.00(PLE4SEPAW17VINK 04YTPEALL TION City or Town op k Date: l7 To the Inspector By this application the a of Wires: �10 undersigned gives noti of ns or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant -1 VNA Owner's Address Telephone No. (­4( Is this permit in conjunction with a building permit? yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Service —volts Overhead Undgrd New Amps No.of Meters ----.L—VOlts OverheadEJ Undgrd❑ Na.of Meters Number of Feeders and Ampacity Location and Nature Of Proposed Electrical Work: Cam letron 0 the ollowin IaN emgvbewaive±" the Ins ector.0fWires. No.of Recessed Luminaires NO.Of cen.-Susp.(Paddle)Fans 0.01 ota No.of Luminaire Outlets Transformers "YA No.Of Hot Tubs Generators KVA No.of Luminaires Swimming Pool bove m n- iiii I icy ig ng No.of Receptacle Outlets No.of 11 Oil,Burner's rnd. — rn ❑ Batte nits No.of Switches FIRE ARMS No.of Zones No.of Gas Burners 0.0 etectton an No.of Ranges Initiating Devices No.of Air Cond. Ote Tons No.of Waste Disposers eat ump um No.of Alerting Devices 0.o el-Contam No.of Dishwashers Detection/Alertin Devices Na.of Dryers Space/Area Heating KW Local 0 Unicip Connection 0 Other Heating Appliances KW ecunty Systems: 0.0 ater �—0. Na of D--1 ­:.,alent Heaters KW i 0.0 Data Wiring: Ballasts Devices or E invalent No.H e ydromassage Bathtubs No.of Motors Na of De vi* Total HP ecOmmunications i n OTHER: ent Estimated Value of le A4 additional detail if desired'cal Work: 'e or as required by the inspector of Wires. municipal policy.) Work to start: (When required by Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVE RAG 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. e undersigned certifies that such coverage is in force,and has exhibited Proof of same to the permit issuing office. Th CHECK ONE: INSURANCE nx BONDE3 OAR 0 (Specify:) lCertify,under the pains and penalties of perjury,that the information on this application is truean complete. FIRM NAME: Ni ihtwatch Protection Inc. d Licensee: Paul Dels"Janor Signature LIC.NO.: 7024C (If applicable, enter "exempt"in the�,�en��number line) LIC.NO.:7024C Address: 22 Briarwood Drive Westford, MA 6886 Bus.Tel.No.-8 .Tel.No *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt Lic.No..: ��S-0016�96 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. 1 am one ❑owner Owner/Agent the(check El 0 owner's agent. Signature - Telephone No.----.I PERMITFEE.• S 2 1, t C_ �, J �)m,I �\ 1 ne c,ummonwealrn of 1wassacnusetts Department oflnduslrialAccidents Office oflnvestigations l Congress Street, Suite I00 U9F 0 Boston,MA 02114--20.77 Workers'Compensation Insurance Affidavit: Buildes/Contractors/EleeWc>ans/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Nightwatch Protection, Inc. Address: 50 A Northwestern Dr. Suite 9 City/State/Zi : Salem, NH 03079 Phone#: 888-722-9282 F3.001 an employer?Check the appropriate box: a employer with 13 4. [] I am a general contractor and I Type of project(required): loyees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on the attached sheet. 7. [�Remodeling and have no employees These sub-contractors haveing for me in any capacity. employees and have workers' 8' EJ Demolition workers' comp. insurance comp. insurance.t 9. ❑Building addition ired.] 5. 0 We ate a corporation and its 10.n Electrical repairs or additions a homeowner doing all work officers have exercised theirlf. [No workers' comp. right of exemption per MGL 11•[]Plumbing repairs or additions nce-required.] t c. 152, §1(4),and we have no 12•❑Roof repairs employees. [No workers' 13.W Other Sec.Syst-Low Voltage comp. insurance required.) 'Any applicant that checks box#]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.. employees. 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. information. 'am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site Insurance Company Name: Hartford Insurance Co. of the Midwest Policy#or Self-ins. Lic. #: 76 WEG EV7027 -- _ Expiration Date: 12/10/2014 Job Site Address: �� f-y-n l.)�y--\ S � 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 o. 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. 'do hereby certify under the pains and penalties ofperjr:.y that the information provided above is true and correct 'i afore: ry Date: hone#: v CCU. 7 )(� 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): I.Board of health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other :70ntact Person: Phone#: i { AUTHORIzED Nightwatch DE/iLER Protection, Inc. 50A Northwestern Dr.,Suite 9 Salem,NH 03079 15 H011y St.,Suite 208 Kevin Gilligan Scarborough,ME 04074 President toll free(888)722-9282 x121 kg @ nightwatchprotection.com www.nightwatchprotection.com Commonwealth of Massachusetts Department of Public Safety Security Systems-S-License License:SS-001696 oE, , PAUL DELSIG90 � 22 BRURWOOD Westford MA:618 ' Commissioner Expiration: 01/25/2016 Fold,Then Detach Along All Perroratlons 00MRIONlY LTIJ OF MA -ACIjUSM I C I ANS ISSUES THE. FOLLOWING LIMRSE AS � A REGISTERED SYSTEM COMTRACTOR gg NIGHTWATCH PROTECTION INC PAIUL J DE.LS I ONOR 22 6R I ARVOOD DR I V WESTFORD !MA 01886-1165 .3 �,-• 7[024 C _ .�07�7/31/1.6 50372 . I I ' l E SUMMARY OF INSURANCE Tx�'i �iTFORD FOR: NIGHTWATCH PROTECTION INC Prepared:12/10/2013 50 NORTHWESTERN DR # A UNIT 9 SALEM NH 03079 Phone: FAX: BY: HOME OFFICE PAYCHEX INSURANCE AGENCY INC 210705 PO BOX 33015 SAN ANTONIO TX 78265 Phone: FAX: (888) 443-6112 ACCOUNT POLICY RECAP Policy Number Eff Date Exp Date Premium Workers' Compensation 76 WEG EV7027 12,102013 12102014 Hartford Underwriters Ins Co POLICY DETAIL Policy Workers Compensation Policy States: ME MA NH Location 01 Premises Address 15 HOLLY ST SCARBOROUGH, ME 04074 Location 02 Premises Address 22 BRIARWOOD DR WESTFORD, MA 01886 Location 03 Premises Address 50 NORTHWESTERN DR• # A UNIT 9 SALEM, NH 03079 Worker's Compensation Coverages .Employer's Liability Limits Limit Disease - Policy Limit $500 000 Disease - Each Employee $100, 000 Each Accident $100,000 _Individual Included/Excluded Class/Payroll Detail Class Description Class code Payroll #of Location 01 - ME SALESPERSONS OR COLLECTORS - 8742 $56,293 Location 02 - MA FIRE ALARM, TELEPHONE OR 7601 $80,189 Location 02 - MA SALESPERSONS, COLLECTORS OR 8742 $36,329 Location 03 - NH AUDIO OR INTERCOMMUNICATION 7605 $117,134 Location 03 - NH SALESPERSONS OR COLLECTORS - 8742 $48,580 Location 03 - NH CLERICAL OFFICE EMPLOYEES NOC 8810 $312, 969 This summary and its attachments provides high level overview Of policy coverages and does not include all conditions, limitation or exclusion. Please refer to the actual policy forms for detailed coverages, limits and deductibles. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `../ 10/3/2014 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 CONTACT Melissa Pflug g Mackintire Insurance Agency Inc PAIC_HONE (508)366-6161 F°`XNol:(508)366-5202 11 West Main Street A,MDResS:melissap@mackintire.com INSURERS AFFORDING COVERAGE NAIC N Westborough MA 01581-1931 INSURER A:Steadfast Insurance INSURED INSURER B Nightwatch Protection Inc INSURERC: 50 A Northwestern Dr. INSURER D: Ste 9 INSURERE: Salem NH 03079 INSURERF: COVERAGES CERTIFICATENUMBER:14-15 Master 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE OCCUR OL9836125-00 9/1/2014 9/1/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Uninsured motorist combined $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 51000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 51000,000 DIED I X I RETENTION$ 10,000 AUC0135250-00 9/1/2014 9/1/2015 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N L Ll� ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ A Errors & ommission8 OL9836125-00 9/1/2014 9/1/2015 EACH OCCURRENCE $1,000,000 DESCRIPTION OF OPERATIONS/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 Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Timothy Moynagh/MEL ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgntnnsi nt The Arr1R11 name nnrl Inn^arc renicferc/i mnrtre of Arr1Rn