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HomeMy WebLinkAboutInsurance Letter - Permits #12247 - 184 COTUIT STREET 3/24/2014 Date E NowrN�a TOWN OF NORTH ANDOVER f _ PERMIT FOR WIRING * r ,BBaCHUBfa This certifies that % .. has permission to perform ........................." :. ................................................. f wiring in the building of,.,,.,,;: .,�. ..::� .....�. .. at .......�.:: r,.............................. ... r ` ........................North Andover,Mass. Fee....... Lic.No.t... ....... .. } . .... ELECTRICAL INSPECTOR a Check# �- E.E P of Forth co�mmonw"a o/M,46 cl .ffJ Official Use Only d[.JePartmant o��ire�arvice� Permit No. I IT-4 1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 IN INK OR TYPE ALL INFORMATION) Date: ';,�I 2k)I A City or Town of: Dora n,v8oyeR To the Inspec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ► k y Co4 u r+ }- Owner or Tenant `S"�P Reel LA SC_-l g Telephone No.Q 9%-(cgt$16404 Owner's Address Same as above Is this permit in conjunction with a building permit? Yes ❑ No ❑E (Check Appropriate Box) Purpose of Building 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 following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total 7 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA r No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained p Total P ..... ....................................................................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Conne Lion Other Heating Appliances Security Systems: No.of Dryers g pp ' No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters I Signs Ballasts No.of Devices or Equivalent No.Hydromassage 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 Wires. Estimated Value of Electr' al Work: $650.00 (When required by municipal policy.) Work to Start: �0 �� 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete FIRM NAME: Northeast Electrical Services INC. LIC.NO.:20782A Licensee: Daniel B. Kobus Signatur`T:,y ,j J LIC.NO.: (If applicable,enter "exempt"in the license number line.) � Bus.Tel.No.:508-966-7467 q® Address: 40 N. Main Street P.O Box 361, Bellingham, MA 02019 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)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. I PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations d I Congress Street, Suite 100 Boston, MA 02114-2017 °qM z.a www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Northeast Electrical Services Address:40 North Main Street, P.O Box 361 City/State/Zip: Bellingham, MA 02019 Phone #: 508-966-7467 Are you an employer? Check the appropriate box: Type of project(required): I. I am a employer with 24 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 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. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.n Electrical repairs or additions officers have exercised their 11. Plumbing 3.❑ I am a homeowner doing all work g repairs pairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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 Agency Inc. Policy#or Self-ins. Lic. #: NOWC428117 Expiration Date:7/29/2014 Job Site Address: «S�' CQtU I t (>_ City/State/Zip:l�d. n C1y ��% J 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. Si nature: Date: -3 zo , Phone#: 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 KHM1 , 6- O, o' CERTIFICATE OF LIABILITY INSURANCE F73/512014 YYY() �� 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: Automatic Data Processing Insurance Agency,Inc PHONE FAX 1 ADP Boulevard A/c No Ext: a/c No: Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:AmGUard Insurance Company INSURED Northeast Electrical Services INSURER B: PO Box 361 INSURER C: Bellingham,MA 02019 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 MAYHAVE BEEN REDUCED BYPAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICYNUMBER MM/DD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED - PREMISES Ea occurrence $ CLAMS-MADE OCCUR MED EXP(Arty one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LMrr Ea accident $ ANYAUTO BODILY MURY(Per person) $ ALL OWNED SCHEDULED SOD LY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X I TCR WC STATU- OTH- AND EMPLOYERS'LIABILITY YLIM ER A ANY PROPRETOR/PARTNERJEXECUTNE Y/N NOWC428117 2/25/2014 7/29/2014 E.L.EACHACCIDENT $ 1,000,000 OFFICERMIEMBER EXCLUDED? a N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMrT $ 1,000,00 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ...�- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD ACC>REPCERTIFICATE OF LIABILITY INSURANCE D /DD/YYVY) 9/5/25/2013 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 Denise Thomas, CISR, AAI NAME: R.S. Gilmore Insurance Agency, Inc. PHONE (508)699-7511 aCN :(508)695-3957 27 Elm St. ADDRESS:dthomas@rsgilmore.com P. 0. BOX 126 INSURERS AFFORDING COVERAGE NAIC# N. Attleboro MA 02761 INSURERA:Travelers Indemnity Company 25658 INSURED INSURERB:Safety Indemnity Insurance Co. 33618 Northeast Electrical INSURERC: Po BOX 361 INSURER D: INSURER E: Bellingham MA 02019 1 INSURERF: COVERAGES CERTIFICATE NU_MBER:CL139541833 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 ADDLTYPE OF INSURANCE =11 SUER POLICY NUMBER MMfIDDDY EFF MMIDDY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE ToRENTE X COMMERCIAL GENERALLIABILITY PREMSES Eaoccu ence $ 300,000 A CLAIMS-MADE ❑_x OCCUR 6807493R363 9/2/2013 9/2/2014 MED EXP(Any one person) $ 51000 PERSONAL&ADV INJURY $ 11000,000 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 t SINGLE LIMIT 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6211040 9/2/2013 9/2/2014 BODILY INJURY(Per accident) $ HIRED AUTOSN AUTOS AUTOS NON SWNED PROPERTY DAMAGE $ inCl X Per accident) X PIP-Basic $ 8,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 11000,000 DED RETENTION CUP557M3866 9/2/2013 9/2/2014 $ LIt WORKERS COMPENSATION WC STATUS O R AND EMPLOYERS'LIABILITYYIN ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? El (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/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ID # 264516664 - Sears Roebuck and Co. and its affiliates and subsidiaries are additional insured under the general liability & commercial automobile liability coverage as required by written contract. Town of Andover is additional insured when required by written contract. CERTIFICATE HOLDER CANCELLATION (847)747-9066 c5556cc@oearshe.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NCglCE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sears Roebuck and Company and its affiliates and subsidiaries AUTHORIZED REPRESENTATIVE 7353 NW Loop 410 San Antonio, TX 78245 Tim Gilmore/DTHOMA �r^'-�"� -�,--, JQ_' ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. 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