HomeMy WebLinkAboutWire Permit - Permits #13181 - 160 CANDLESTICK ROAD 3/26/2015 \ _
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('�antnoiuveattk 01 Ma,3617C1141-30tb 01--,ial Use Only
Permit\110.
5-10 rj.-
2cparinixid ol-)Ire-Servicei
Occupancy ccupancy and Fee Checked
[Rev.
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (le--kknk)
PERFORM ELECTRICAL WORK
APPLICATION FOR PERMIT TO Electrical Code(TVIEC ,527 CN 12.00
All work to be perron-ned in accordance with the Massachuseus ----
F I Date:
(PLEASE PRI.AIT 11V 1INK OR D ALL 1X Rill.4 OjY)
�F To ihe In4spoclor Of --rives:
City or Town of: 0 perform the electrical ork described belo%v�
By this application the undersigned Gives notice is or her intention t
Location(Street &- Number) Telephone No. '°
Owner or Tenant
Owner's Address
na permit? Yes E] No [�J� (Check Appropriate Box)
Is this permit in conjuncpi�n with building a Utility Authorization Na.
fB Id )C-,�"V/ I
Purpose o ut ing , Z/ Volts Overhead El UndgrdEj No.of Meters _
Existing Service Amps — /
I Volts Overhead F1 [jnd-rdE] NO.of''Meters _
New Service Amps
Number of Feeders and Amp2cih
Location and Nature of Proposed Electrical"Work:
zw 14e
Con1plelioll offile foliowinz table main he waji-edbr ilie.hispector of
.of Total
No.of Recessed Luminaires No.of Ceil--Susp.(Paddle)Fans Transformers KVA
Generators KVA
No.of Luminaire Outlets Na.of[lot Tubs AboveE] I n- tang
No.of Luminaires
Swimming Pool �rnd arnd. ❑ Battery Units
FIREALAWNIS \11o.ofZones
N io,of Receptacle Outlets Na.of Oil Burners I "I
I ro.of Detection and
Nc o.of Switches No.of Gas Burners I - Initiating Devices
-- Total No.of Alerting Devices
o.of Ranges
No.of Air Cond. Tons
KNNI No.of Self-contained
Heat Pump number Tons ina Devices
No.of W,Iiste Disposers Detection/Alert! -
zl
Local unt ction Ej Other
IN,0.of Dishwashers SpacelArea Heating, KNV Connection
Security S-,'Stems-v
Hearing Appliances I Na,of Vy-;PPz nr Fouivalen,
No.of Dryers No.
No.of Water of No.of Data Wiring: lent
Heaters KW BSignsallasts No.of Devices or Equivalent
e ecommunications Wiring:
No.Hydromassave Bathtubs No.of Motors Total HP I No.of Devices or Equivalent
OTHER- rrecf.or as equired bi'the Inspector of lVircs
Estimated Value of Electrical Work: (NN'lien required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion_
INSURANCE COVER-AGE: Unless waived by the owner,no permit for the performance ofelectrical work may issue unless
it,-4�completed operation`coverage or its substantial equivalent. The
the licensee provides proof of liability insurance including overn -nit issuino I 6f-fi c e.
undersigned cerLifies that such cave W Be is in force,and has exhibited proof of same to the pen
CHECK OK: INSUR.1kN1Cf1'Rr ONID n OTHER n (Specify:)
all this application is true,and coiglete.,
I cerlift-,jinder the p0gis flird�enalfies ofperjuyy,that the hifor"ladoll
F M NAM]f C- a ��;e
NO.:
-T- Signature LIC.
Licensee: I 4P 4- ZF Ir C�'I"',�-(f q.- ' ' Bus.Tel.N0-:
(if applicable,enter"exempt"in the lic 1 n se eV_ t No.:
Address: q-1 .. �2,4-t(',/ %1, o 1 1 At .Tel.
211'er M.G.L.c, 147,s.57-61,security work requires Department 01 Public Safety"S' License: LIC.No.
does 1101 17al-e the liability insurance covera-=e normally
OWNER'S INSURANCE WAIVER: I am aware that the Licensee do t. I am the(check one)F]owner n ow I s aaent,
required by law, By illy signature below..I hereby\vaive this requiremen
Owner/Agent Telephone Na.
PERAII T FEE: S
Signature
TC,,./', L(A 29) D
E F LI I DATE(MIarl7DrvYYYI
0915 Df2014
THIS CERTIFICATE IS ISSUED AS A PATTER 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 poliey(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).
-RODUCER CONTACT
MARSH USA,INC. NAME:
TWO ALLIANCE CENTER PHONE FAJJCC.No):
3560 LENOX ROAD,SUITE 24DO E-MAIL
ATLANTA,CA 30325 ADDRESS.
Attn:Atlanta.CertRequasb§marsh.com I Fax:212.948-4321 ENSURERS AFFDRDtNG COVERAGE NAIL
605106-Speed-Cas-14-15 Speed INSURER A:ACE An»ricm Insurance Company 122667
NSURED INSURER S:Indemnity Ins Co Df North America 143575
MasTee North America,Inc.
Speed Wire,Inc. INSURER C-Commerce And Industry Ins Co ID410
800 Douglas Rd.,Penthouse_
Coral Gables,FL 33134 INSURER D
INsuRrax E:NIA NIA
INSURER F.
COVERAGES CERTIFICATE NUMBER: ATL-0032625OR3 REVISION NUMBER-2
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.
NS TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP
POLICY NUMBER MMlDDIYYYY MMiDD LIMITS
A GENERAL LIABILITY XSL G27336589 OW1512014 0911512015 EACH OCCURRENCE 5 1,750,D00
X COMMERCIAL GENERAL LIABILITY DAMAG N 25D,OD0
PREMIS Ea a;...currence
CLAIMS-MADE OCCUR MED EXP(Any one person) NIA
X SIR:$250,DOO PERSONAL VADV INJURY 5 1,750,ODD
GENERAL AGGREGATE S 20,006,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/DP AGG $ 6,ODO,ODU
X POLICY PRO LOC S
A AU rOMOBILE LIABILr"rY ISA H08927667 0911512D14 09hM015 rEefiacctleMSINGLE LIMIT s 5,000,000
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per $
AUTOS AUTOS ( I
NON-OWNED PROPERTY DAMAGE S
X HIRED AUTOS X AUTOS Par W=Ident
5
C X UMBRELLA UAB X OCCUR BE 15805711 09/1512014 0911512015 EACH OCCURRENCE S 5,00,0DO
EXCESS LIAR CLAIMS-MADE AGGREGATE 5 5,0D0,0D0
DED I I RETENTIDN 5 I$
B WORKERS COMPENSATION WLR C48017010(AOS) 0911512014 0911512015 X I WC sTATu- OTH-
AND EMPLOYERS'LIABILITYDR
A ANY EMPLOPROPRIYERS'
A LIABILITY
YEXECUTIVE YIN WLR C48017022(AZ,CA,MA) D911512014 0911512015 �� 2,ODO,000
DED? RE N I A E.L EACH ACCIDENT S
OFFICERIMEMSER EXCLU _
A (Mandatory In NH) WCU C4BO17046(FL,GA,NC,TX) 09/15/2014 09115/2015 EL DISEASE-EA EMPLOYEES _ 2,000,DOO
It Yes,dascrbs under SIR:$1.5M for FL,NC,TXt$1 M for GA 2,OOD,00O
DESCRIPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT -S
A Workers Compensation SCF C48017D34(WI) 091112/14 1111112111
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is requlred)
Re:Of a Machines-Installation,Repair,Service
CERTIFICATE HOLDER CANCELLATION
Speed Wire,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE:
8DO Douglas Rd.,Penthouse THE EXPIRAT)ON DATE THEREOF, NOTICE WILL BE DELIVERED IN
Cora!Gables,FL 33134 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukher)ee as a�siti: .:r+ te,:,1.•, r t
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
SOAR
tSSLtES THE FOLL0 1N5 LICENSE AS A y
R'EGISTEREII MAST ER:: ELECTR1CIAN
z
�E"EEDWI RE INC
cHR I STOPKER: THE BLAIf Aul
uk
57 �iARR{5 5T
► ORTW ADAM ,MA o1247--233
18365 A; 07/31/1 , 36270
It Department of Pubkur 'pat ty
1, tlfYl� 'I'd,Yn, K.lix::1•
P_ce se- S5-001895 � r
CHRiSTOPUER J TRE,�VS 3LA�Y ra
393 Jericho TpJw S6 "
Mineola NY 1.1501
tia caaraau6ran�arer 05/24/2015
".1 The Coinnionwealth of Massachusetts
Z
Departinent of Industrial Accidents
Qf ce o fi f Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
)vjvu,.mass.goi,1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsiElectricians/Plumbers
Applicant Information Please Print Leib
al
e Wire, Inc.
NaMC (Business�Organization/Indjyidu'al):
,4p,'
Address: 806 S Douglas Rd 10th Floor
CityjSt�te/dip'. Coral gables, FL 33134 ,�,%
Dge 56'1,254-8610
Are you an employer? Check the-appropriate box:-
Type of project(required):
F-01 I am a employer with 10 4. F] I am a general contractor and 1 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
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. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.'+
required.] 5. We are a corporation and its 10.F] Electrical repairs or additions
El I am a homeowner doing all work officers have exercised their I LR Plumbinc, repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] c. 152, §1(4),and we have no 12.R Roof repairs
employees. [No workers' 13,RM Other Burglar Alarm
comp. insurance required.]
,ny applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
forneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
tployem If the sub-contractors have employees,they must provide their workers'comp,policy number.
un an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
formation.
surance Company Name:ACE American Insurance Company
dicy 4 or Self-ins. Lie. #:WLR C48017022 Expiration Date:9-15-2015
b Site Address: All Locations City/State/Zip:
each a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
to 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
up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the 9k9"nsurance coverage verification.
Fo hereby eerti. u er ie pains a7id penalties of perjury tlzat the itifortitatioizprovided oil stru nd correct.
4
-mature: Date:
one 4: 254-861
Offledl use only. Do not write in this area,to be completed by city or town officiaL
City or.Towu-, PermitJLicense 9
Issuing Authority (circle one):
7 1. Board of Health 2. Building Department 3. city[rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: