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Home My WebLink AboutWiring Permit - Permits #13260-1 - 595 CHICKERING ROAD 4/11/2016 �� iii/p � �r�%in ✓��i��i,ire e�rym 1 ld j; OWN NORTH AND OVER ii%%' "" / PERMT_....._._._._._,.....___�_ _...� j r �o�/ A 'his c eil t:hr�t ..... .. . Pr.. has pernfission to pcaform V i/10/ witing in tbe imfildingk� "rth C �g ��ryC Mass. uqp H 0.ti I➢I6)AL,tN al ECI Chit t Y!� �j// �r Ctva i r � �j „, ,,,,,,,,,, , ,>:,: i COMMOnwealth of Massachuseffs (,Ifiidal Ilse Only .. .... a Department of Fire Services Hermit 1*Gct. BOARD OF FIRE PREVENTION REGULATIONS iaate Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wart:to be perforated in accordance,with the Massachusetts Electrical Code(�MEC'`)„527 C;MR 12.00 f (PLE;48E I'RINT IN INK OR TYPE.ALL INIf'ORMATIt.1N) Dante: March 31,2016 thoTo o NORTHf. A DOV To the Inspector of Wires:ByiPpaisff�undersigned g notice of his or her intention to perform the electrical work described below. Location(Street At Number) 595 Chickerin Road , __w....__.____. _ Maly: Lot: Owner or Tenant Sunbanque Tanning Salary Telephone No.978-685-7786 Owner's Address same C r ... .._.__, . Is this permit in conjunction with a building permit? "Yes E No F� (Check Appropriate Box) Purpose of Building Utility Authorization No. �" y Existing Service Am s _ J p Volts Overhead tlndgrd � No.of Meters � New Service Amps Volts Overhead llnd rd � p g No.of Meters Number of Feeders and Ampacity _ lLocation and Nature of Proposed Electrical iArork; Remove and replace fire damaged transformer rrF d�tr��ra r„r tl�c '/loom,table rrar be.waived fx tiaas Ira vector Eazr of Wires, r No.of Recessed Fixtures No,of No.ofC"ell Susp (Paddle)Fans Total Transformers KVA No.of Lighting outlets KVA of not 1 uhs _. Generators KVA No.of Lighting Fixtures Swimming Pool , b e r In a»to ..mergenoy tg tmg roil. grne. a-tte Units 1 No.of Receptacle Outlets No.of foil Burners .__ FIRE ALARPVIS No,of Zones - y No.of Switches No.of Gas Burners Na.of Detection and. �Initiatin Devices l No.of Range's Total No.of Air C and Tons g No,of Waste Disposers Ileac Isirrnp Nurntrer Ions KW No.of Self-C;ontaiiued Devices _w .. artals Detection/Alertin1 Devices No.of Dishwashers Space/Area heating KW Local � municipal1011 Connection 0 Other No.of Dryers heating Appliances KW SecurNY Systems: i No.of Water --------�---�— ....-. ............ Nrts of Devices or E uivalent Nam.of .__._._ _....._, Heaters W No,of Data Wiring: Si as Ballasts No.o�f:Clevices or E uivalent Y g No.of Motors Total III No.H dramassa o Bathtubs Telecommunications Wiring: % —._- No.ofDevices or E uivalent j OTHER: --.-�w_. ___ __._. �ttac/a car/tPatrrsal aXe rczcC "tdey:re�d e r°aro r a:cpatarecC dot tkc/ras/xeco6rrr°oj,Wipes. Estimated.Value of Electrical Work $390.00 (When required by municipal policy.) Jr Work to Start; 3/31/16 Inspections to be requested to accordance with M C:Rule 10,and upon completion. INSURANCE COVERAG.E; [less waived by the yawner,no permit for the performance ofelectrical work may issue unless the licen- see provides proof of liability insurance including"Completed operation"coverage or its substantial equivalent. The undersi ned certifies ,that such coverage is in farce,and has exhibited proof"of same to the permit issuing office, g CIIF:CK ONE: fN5[JFC.AIVCp ED HC7AJl) 0 C7'1"Ill,lC [ (Specify:) i certify,under tie pains anuC penaltfes oj"p,erjrer.Y,,that the information can a`{rdv application is true and complete. �! FIRM Licensee:NAME: Andover Electric Services.Inc ._. LTC'.�NO.: 44302 Robert J. Branca _ Signature *Per�M M.G. c. �147,s.57-61,security work requires Department t'r'h 1''tablau a6t t S^l iceprst. _...__ L IaC.NO., Y r t Y LIC.NO.. S: Adedr+ess.619er�ar,"exempt°'era the,Caec,rase raasrrtbe,r"dartee.,d d ale t Andov r, l�lA Bus Tel No 5t7f1-475..4g95 j din"` i Alt Tel No.: yT8-42_�R l5p /�; OWNER'S INSURANCE WAIVER. lam aware that the Lrc nsee doea root lrrxve the liability insurance coverage normally required by law. By my r signature below,l hereby waive this requirement, l am the(check one.)[�owner �owners agent,Owner/Agent Signature._. , FP-rmit I ee. 12S.f)0 _.._ ...._ l'ltorie _._... . l r he Commonwealth Massachusetts Department ref'Andustrlal Accidents Office of Investigations .1 Congress Street,Suite 100 Boston,MA 02 114-20,17 www.mass., ov1dza Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(.BusinessrOrganirazie)n/individual): Andover Electric Services, Inc. address:19 Dales Street 1 i r City/State/Z.i :Andover„ CIA 01810 Phone 4:978-475-4995 .Are you an employer'Check the appropriate box. I F7. ype of project(required): 1.[ I am a employer with 5 �. �] l am a general contractor and 1 employees(full anchor part-time). have hired the sots-contractors New construction. 2.❑ I am a sole proprietor or partner- listed on the attached street, E]Remodeling ship and have no employees 'these sub-contractors have , �I7errtolition working for me in any capacity, employees and have workers" s [No workers' comp. insurance comp insurance t 9. Building addition r required.] 5, e arc a crrrpor�atron and its 10,El Electrical repairs or additions 3.❑ i am a homeowner doin r all work officers have exercised their € 11..®Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. 1 ' 1.2.[]hoof repairs insurance required.] §l(4' and we have no employees. [No workers' 13.0 Other comp,insurance required] 1, 'Any ttptaCivant that checks kitix#f t must ate;<r tilt out the::caCicrii fieGaiw s4a<iiroint;their wteukc rs'acrsiarroc^n:<itioaa policy iittaiaati<rrion. l homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating;such. 0 rCont,ractors that check this box must attached an additional sheet showing the natne of die sub-contractors and state whether or not those entities have: j employs. If the sub-con tractors,have cnitrNoyurs,they now provide their wairlccxs'u°wa�ntZ.Rohe°°.y nn¢iiticr. i ant an etnplrryer that is providing,workers"compensation insurance for arty employees. Below is the policy and/ob.rite information. Insurance Company Name:The Hartford _.... ..w __,__._ _.... _.... ...�..................._........ Policy#or Self ins. Lie.#:08 WEC CM5940 Expiration Date:4/28/16 Site 595 Chicker�iri Road Attach ch a copy of the workers compensation policy declaration page showitt rt��; 'tate/Gi North Arrcicryer, IWQA 01845 p ' p`g ( e policy number and expiration date). Failure to secure coverage as required under Section 25A of1`vlGL c. 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORKORDER and a tine 1 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 air!� d` en tes o as p „irperjury that the information provided above is true and correct. r —Signature: 3/31/ 016 re� ,,� r' w. Date• r Phone#: 976- 1 4996 f% Official use only. Do not write to this area,to be completed by city or town o racial. � �R rt City or Town; _w Permit/License# issuing Authority(circle one): 1.Board of Health 2.Building Department da City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: _ Phone#. T ,,,.J/liiii,,,, j r DATE tNUlooaYvvYl Cto►RO* CERTIFICATEF LIABILITY INSURANCE 03/31/2018 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 Pollcy(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 endorsementis)„ PRODUCER Phorke:(978)474.0810 Fax:(978)474.0890 CONTACT Samal Insurance Aganay,lnC. JONATHAN M SAMEL CIC LIA -- ----- —n -. -....- 1 d If itdr r:AX SAMEL INSURANCE AGENCY,INC. w9 N��;.._�� 74 tYS10.__„ . � 97NI.474-0NI9Q rualL Info samal-lns.15 CENTRAL STREET ADk„r�.._......._.......�........................._...coin.._..................._._...._...__.. _._____,__.__ -_�......._...._ ANDOVER MA 01810 INSURER(S)AFFORDING COVERAGE Nwaa NaIxRERm Sentinel Insurance Co,LTD 11000 liddlRCY..,,...._..,....._.,.,�..._._......._._ _.____._... ........_....................._.. ......... _....._ ANDOVER ELECTRIC SERVICES INCINSURERe Citation Insurance Company 40274 PO BOX 629 INSURF,Rr :Sen'ffnel Insurance Co LTD 110 0 ANDOVER MA 01810 INSURERo, Hartford Fire Insurance Company Comparty 19682 IN9URtiR F COVERAGES CERTIFICATE NUMBER.451'89 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF kNSURAMCE LISTED BELOW HAVE BEEN kSSiJED TCb THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUtRE4wtEMf,TERM CYR CONDITION OF ANY CONTRACT CJR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN„ THE INSUIIANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ION NDkTI F I Ir H W H M R Y PA' i IN9R f4CN'A'L.G1UER .LT _ TYPE OF INSURANCE PaLkGY NUMat:R POLICY Err PaUaY EXP ......._........._..El.;ltK, WYJ7. .......-_..... .._......... ...._._..._._........_..L �..... 19:8'EpkY.YYYI LkwaT$_...._____ __........... ._.......GENERAL LweaL°r" 085BAIL4328 03123J78 03/23A17 EACEI OCCURRENCE $ 2,000 000 X COMMERCIAL GENERAL LIABILITY RREa4rsEs EaocCuanCay CLAIMS-MACE X�OCCUR .__._...$.........._,,.,..... 1,000,000 MED.ExP(Any One Person) $ 10,000 .-.. PERSONAL 8.AD'V INJURY $ 2,000,000 GEaERALApGREGATE __._ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: .._ ._.__.....___.._....._.._...__,.,.._ PRODUCTS-C(MdP/OPAGG $ 4,000,t1� POLICY x j: LOC $ _ x _... _ _....._ ....__ _ ... AurauaalLE LIABILITY _._., B KW7918 03123/16 03/23117 ('ONSINED SINGLE LIMIT_. f ANY AUTO EaaCeI eII __ $ 11000,000 BODILY INJURY _. ^.-ALL OWNED SCHEDULED (Per parson) $ ..._AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED hr �. AUTOS r15aEarwbAM E_ $ (Irer amoM�ns7_ ........,. _._. C .._.... X pCC ..._........._._,..X UMBRELLA Ewa CUR 085BAIL4328 03/23/18 03123/17 EACH OCCURRENCE $ 2,000,000 Y ExaERa Lwa t"LAIMS'CAtADE - _..-...._ AGGREGATE $ 2,000,000 DEDT7 REEENTICIN$ 10,000 ----,-.__...._._...__..._..._ ..... _. $ D WflR16ERs aarxPENsaTesN 08WECCM5940 28/15 04128d17 X wC.�tT r�f4 AND EMPLOYERV LIASIUTY rCYRY LIMITS E'R $ G YIN1.. .._... ANY PRMEMBER EXCLUOSD?EaaTrvE FL EACH ACCIDENT $ 5011,000 (Mang tRrMEMaeR EXaLUaE'D? NfA ._ .- ... laaattPadory In MR) E L DRSEA$E-EA EMPLOYEE $ It yes deealbe oan,9mr - _._...,-- _ ._...`. .,,.5(I 0,000 saPnoN aE aPEnAriarvs bet w E L,DISEASE-Pctp ICY LtMir $ 500,000 _...__.. l DE$CRtPTIDW 6F aWERAT1aN$!LaCATIaw$/VEwICLE$(AnaCh ACORD let,Addteenai Remarks Schedule,Ir m om a .�-....�pees 4s required) Operations typicat to commercial and residential electrical contractor, j �r CERTIFICATE HOLDER CANCELLATION r _ 1% Town ofNorth Andover 16f10 Osgood SHOD ANY OF THE ABOVE PJSED POLICIES BE CANCELLED BEFORE good Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN l Building 20,Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS, North Andover,MA 01845 rx Attention: rJr If ACORD 25(2010105) .- . Jonathan M.Samel 1988-2010 ACORD CORPORATION, All righta reserved, The ACORD name and logo are registered marks of ACORD l"' ........................... ...... ................uuuuuu a w u..................... CERTIFICATE OF LIABILITY INSURANCE DATE (MMJDD/YYYY) 03/3112016 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: H the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed, If SUBROBATION IS WAIVED, subject to the terms anti conditions of the Policy,certain policies may require an endorsement.A statement on this cortillicate,does not confer lights to the certificate holder in lieu of such endorsement(s), PRODUCER PhOne:(978)474di810 Fax:(978)474-0890 CONTACT s JONATHAN M SAMEL CIC LIA Intel Insurance Agency,Inc, PHONE ..........--- SAMEL INSURANCE AGENCY,INC. 97S-4?4-0_81Q_______ Mlgjjqi,,_ 978,474-0890 r-MAII, 15 CENTRAL STREET J=ft6a___J! I.Ins.corn ............. ......------ ANDOVER MA 011810 INSURER(S)AFFORDING COVERAGE NAIL# ................. INSURER A �Sentinel insurance Co,LTD 11000 ;§UJ....... . ..... ................... ............. .......... ANDOVER ELECTRIC SERVICES INC 'N"'RER" Citation Insurance Company 40274 PO BOX 629 INSURERC Sentinel Insurance Co LTD 111000 ANDOVER MA 01810 INSURERN Hartford Fire Insurance Company _19682 INSURER INSURER F COVERAGES CERTIFICATE Milfifing REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICI OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT' ABOVE FOR THE POLICY PERIOD ED DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I F I WN MAY_ I INSA Y PAi TYPE OF INS�N�!. A 1 SUBA POLICY Err POLICY EXP LIMITS A GENERAL LIABLITY OBSBAIL4326 03123/16 03123H7 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY V 1,000,000 CLAIMS-MADE OCCUR __-1 rJ MEU.EXP(Any one person! $ 10,000 PERSONAL&ADD INJURY P 0 POLICY 3 2 Y 3 Y Err p 0 3 C 2 'M y 3 E X y y 7 L $ 2,000,000 .......... ................... ................ GENERAL AGGREGATE 4,000,000 GEN'L AGGREGAT E LIMIT APPLIES PER ........... PRODUCTS-COMPIOP AGG $ POLICY__X_' PRO, ............. ....... 4,000,000 ............. ... ........ 7 POLICY NUMBEN 8 AUTOMOBILE LIABILJTY ...... $ KW7918 703/2311603/23ti7 ANY AUTOI.___................. $ 1,000,000 ALL OWNED SCHEDULED BODILY INJURY(Per�person) A X UTOS AUTOS X HIREDAUTOS X NON-OWNED AUTOS C X UMBRELLA L ............... -_$ X 4326 03/23/16 03/23/17 EACH OCCURRENCE 2,000,000 OCCUR EXCESS LAS C J ��AIMS-�ADE AGGREGATE 2,000,000 DED X RETENTION$ 10,900' .......... -1-—-— __-L...- _....... ..... $ D WORKERS COMPENSATION ND OT TORY A EMPLOYERS' LIABILITY 08WECCM5940 04128/16 04/28 T !_L_1MTL AG GREGATE ANY PROPRIETORIPARTMERICKSCUnVEyFN _A-1 ET-7, OFFICERIMENSER EXCLUDED? E.L (M..d.w,y In MR) IN N�A EACHACCU)EWr $ Soo 000 E L ............. 501000 If Y.,d.,Abn E.L.DISEASE-EA EMPLOYE UE9CRIPTION Or ATIONS�0- . ........................ ....... E.L. DISEASE-POLICY LIMIT $ 500,000 .......—"—--------------...... roll, DESits CRIPTION OF OPERATIONS]LOCATIONS!VEHICLES(Aftach ACORD 101,Additional Rm earks Sc ................ hadule,It mom space IS mquired) OPO"Stic"Is typical to commercial and residential electrical contractor. lei CERTIFICATE HOLDER �j CANCEL""OLL""HJN Town of North Andover St SHOULD ANY OF THE ABOVE DESCRIBED Street 5 S HE EXPIRATION ION DATE THEREP0,I 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 0,S it T Xp T TE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Suite CCO C WIT Building 20,Suite 2035 T 0 ICY ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 Attention: -/ � Jonathan M.Sarnel The ACORD name and logo are registered marks ACORD�CORPORATIOW All rights reserved. P"' arks of ACORD ........... ........I............ W