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HomeMy WebLinkAboutInsurance Letter - Permits #13227-1 - 124 COTUIT STREET 3/28/2016 iIv.. Date... � � . ............ T TOWN OF NORTH ANDOVER _ p PERMIT FOR WIRING �BACHUS� This certifies that ...... ....... ......... ... `. .. ............................................ ' n has permission to perform f. .......... . �' .... ................ wiring in the building of........................... ... ".`......... ...!......................................................... at tF� F ".:�......................North Andover,Mass. Lie. No. Fee ..... . ............. ....J.. .... .................................................................................... ELECTRICAL INSPECTOR j Check# ' i I I i i i D' Official Use Only Co�nmonuiealth o`cc///a�ac�et� Permit 1JePar?`ment o��ti►e�ervices Ocancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 1r[Revcu1P/0N7]1o' leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ��- f/4, ,,;-7i7 _ To the Inspector o City or Town of: s y, ,�-nr.��%�� P f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant /�I-3 7 �I y3CF/ Cato "/ Telephone No. Owner's Address 0 Is this permit in conjunction with a building permit? Yes ❑ No ❑� (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd El No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install wireless residential security system Completion of the ollowin table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency 1 ng No,of Luminaires Swimming Pool rnd. Elgrnd. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones o.of UFtection an No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump ...,,umber Tons No.of elf-Contained No.of Waste Disposers Totals: Detection/Alertin Devices Municipal Other No.of Dishwashers Space/Area Heating KW Lo�l❑ Connection ❑ Heating Appliances KW Security stems: 5 No.of Dryers g pp No.of Devices or Equivalent o.of Water o.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunicationswiring: No.Hydromassage Bathtubs No.of Motors Total HP I No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: $400 (When required by municipal policy.) Work to Start:J :: V ZI/, Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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 Q BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and.complete FIRM NAME: Nightwatch Protection, Inc. LIC.NO.:7024C Licensee: Paul Delsignor Signature LIC.NO.:7024C (If applicable,enter "exempt"in the license number line) Bus.Tel.No.,•888-722-9.282 Address: 22 Bdarwood Drive,Westford, MA 01886 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. SS-001696 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 ❑owner's agent. Owner/Agent Telephone No. f PERMIT FEE. $ S Sr Signature iLThe Commonwealth of Massachusetts fu Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): .Ni htwatch Protection,Inc Address: 50A Northwestern Drive,Suite 9 City/State/Zip: Salem,.NH 03079 Phone#: 888 722 9282 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 13 4. ®1 am a general contractor and I 6. [3 New construction employees(full and/or part-time).* have hired the sub-contractors 2.(�1 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. ®Building addition [No workers' comp.insurance 5. 13We are a corporation and its required.] officers have exercised their 10.13Electrical repairs or additions 3.03 1 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 12.10 Roof repairs insurance required.]f employees. [No workers' 13.M Other Install w1l sec. systm comp.insurance required.] *Any applicant th_it 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: GUARD INSURANCE GROUP IWC 531842_ Policy#or Self-ins.Lic.#: "- 12/10/2016 Expiration Date: - 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: `— r�c.�C--Gt�_�J��t�2s�� Date: Phone#: 888-722-9282 OJ)7eial 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#: LeAUTHORIZED Nightwatch DEALER Protection, Inc. 50A Northwestem Dr.,Suite 9 Salem,NH 03079 15 Holly St.,Suite 208 Kevin Gilligan Scarborough,ME 04074 President toll free(888)722-9282 x121 kg@nightwatchprotection.com www.nightwatchprotection.com �d Commonwealth of Massachusetts Department of Public Safety License: SS-001696 Security Systems -S-License F PAUL DELSIGNOR 22 BRIARWOOD DR WESTFORD MA 01886 Expiration: Commissioner 01126/2018 Fold.7bon DottchAft AN ft1wagorw EL ICIANS ISSUES THE. FOLLOWING L f IMISE AS 1 A RCOIS71REO SYSTEO CONTRACTOR NIMWATCH PROTECTION INC FRUL 'J DELS ISM 22 OR I Ai41 ND DRIVE WISTFORD XA 01866-1165 ; 7024 C 07/31/14 50372 ACoRV® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDfYYYY) 12/16/2015 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 NAME: Pflug Mackintire Insurance Agency Inc PHONE o t (508)366-6161 FAX A/C No;(506)366-5202 11 West Main Street E-MAIL melissa ADDRESS: p@mackintire.com INSURER(S)AFFORDING COVERAGE NAIC# Westborough MA 01581-1931 INSURER A:Steadfast Insurance INSURED INSURERB:The Hartford Nightwatch Protection Inc INSURERC:Guard Insurance Group 50 A Northwestern Dr. INSURERD: Ste 9 INSURER E: Salem NH 03079 INSURERF: COVERAGES CERTIFICATE NUMBER:2015-2016 update 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 I ADDL SUBR LTR TYPE OF INSURANCE D W D POLICY NUMBER MM/DDYfYEYYY MMIDD�YY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE [i]OCCUR DAMAGE TO RENTED 100 000 PREMISES Ea occurrence $ EOL9836125-01 9/1/2015 9/1/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 X PRO- OTHER: Per Project Aggregate $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT X Ea accident $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED OBUECAX2697 9/1/2015 9/1/2016 BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ Hired/non-owned $ 1,000,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ AUC0135250-01 9/1/2015 1 9/1/2016 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A C (Mandatory in NH) NIWC637378 12/10/2015 12/10/2016 E.L.DISEASE-EA EMPLOYEE $ 500,000 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A ERRORS & OMISSIONS EOL9836125-01 9/1/2015 9/1/2016 LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/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 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE T Moynagh/TRACEY ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(2014011