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Home My WebLink AboutWire Permit - Permits #12368 - 1475 OSGOOD STREET 5/20/2014 RUN, la, \\ , IS �\ I,\ . ate ...... ..... . . .........:. ........... \\ 110 MM TOWN OF NORTH \ ,•` ."• PERMITlk I 1, ggg IM _ \ g gn 1-1 all This certifies that .....�...................................... - -- ................... .............._.. 11 NO: . . has permission to perform ......... ....... .......................................,....................._. P �\ whin in the building of............... MMM ....... ................�...... . .......... , .., ...... i Ow at North Andover, Masse_ _ ... ,- � ° WEBB ML \\ \ .. 'Fees .. )11C. NQ. . ............... .. ......... �..E ...F \ EL car_INSPECTOR Tg �: :. Check ME s Bob ,,i „r„ l ��U��/%�i(%//rr��(�%((��rrIIU/lrrrrlrlIrrrr�r//r/,nr r a�, a rr lir f n 9l 11 1 oJJrJ m ri)JJ JJJJ1 in JJJJJI yJJ Ol Jm 1 »1 )y))� JJ) llJ Jll)J,J�J J)J f J l ,))l,- �l JJl, JllllJ,lJJIJJ,JJ JJ J- r IJ J i u7i i/ J JJ1J Ji l J JJy J J l m J lJ,,i NNW ,/� ,) .✓) )1..J)11JIJ)..., ,ll,l .,�1,)JIJ )J)IJJIJJJJl9D �/ �iri JJI,J )JII,J 1G/I),l)J),�I��;��E�///, Commonwealth of Massachusetts Official U'se Only Department of Fire Services Permit No. J BOARD OF FIRE PREVENTION REGULATIONS Date Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts I.,"Iectrical Code(MEIC),527 CMR 1100 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: May 14, 2014 City or Town of: NORTH ANDOVER To the Inspector of'Wines: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1475 Osgood Street Map: Lot: Owner or Tenant — Police Department Telephone No.978-683-3168 Owner's Address same Is this permit in conjunction with a building permit? Yes F] No M (Check Appropriate Box) Purpose of Building Police Station Utility Authorization No. Existing Service Amps —Volts OverhcadF_1 UndgrdE1 No.of Meters New Service Amps Volts Ovcrheac! ❑ UndgrdE] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: See Attached Completion of thejbllowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of TotalTransformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above Ei In- R o.o mergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Num............. ORS I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal F-1 Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters igns Ballasts No.of Devices or Equivalent No.Hydromassa2e Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail it'desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work $1,090.00 — (When required by municipal policy.) Work to Start: 5/15/14 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 licen- see 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 Z BOND R OTHER 0 (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: Andover Electric Services, Inc LIC. NO.: 14302 Licensee: Robert J. Branca Signature LIC. NO.: *Per M.G.L. c. 147, s. 57-6 1,security work requires Department of Public Safety"S"License: LIC.NO.: S: (If applicable, enter "exempt"in the license number line.) Bus. Tel. No.: 978-475-4995 Address:....19 Dale St, Andover, MA Zip: 01810 Alt. Tel. No.: 978-423-8350 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below,I hereby waive this requirement. I am the(check one)[:]owner D owner's agent. [Owner/Agent Signature Phone: Permit Fee: NO FEE TE c CERTIFICATE OF LIABILITY INSURANCE DA0511azo14 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(les) 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 Phone: (978)474-0810 Fax: (978)474.0890 CONrncr Samel Insurance Agency,Inc. NAM ; JONATHAN M SAMEL CIC LIA PHONE FAX 978.474-0890 SAMEL INSURANCE AGENCY,INC. ( INo Ext: 978.474-OS10 ac No: ss• Info@samei-ins.com 15 CENTRAL STREET PRODUCER ANDOVER MA 01810 T I ; 1254 INSURERS) AFFORDING COVERAGE NAIC IF INSURED ANDOVER ELECTRIC SERVICES INC INSURER A Sentinel Insurance Co,LTD 11000 PO BOX 629 INSURERS :Citation Insurance Company 40274 ANDOVER MA 01810 INSURER :Sentinel Insurance Co,LTD 1100 INSURERD: Hartford Fire Insurance Company 19682 INSURER E INSURER F -- COVERAGES CERTIFICATE NUMBER: 39337 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, INSR TYPE OF INSURANCE ADDT SUSR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER I ID WrAiTB A GENERAL LIABILITY 08SBAIL4326 03123/14 03/23/15 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL �LIABILITY DAMAGE TORENTEDn $ _ 1,006,000 CLAIMS-MADE X I OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY X PRO- LOC $ B AUTOMOBILE LIABILITY KW7918 03/23/14 03/23/15 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $. 1,000,000 ALL OWNED AUTOS BODILY INJURY(Par person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ (Per accident) X NON-OWNED AUTOS $ C X UMBRELLA LIAB X OCCUR OBSBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE 2,000,000 ElccEsa LIAe . CLAIMS-MADE AGGREGATE $ 2,000,000 DEDUCTIBLE X RETENTION $ 10,000 $ D WORKERS COMPENSATION OSWECCM5940 04128/14 04128/15 X RYLI OTN $ a AND EMPLOYERS'..LIABILITY .._.YIN rR ANY PROPRIETORIPARTNER/EXECUTNE 1 E.L.EACH ACCIDENT 500,000 OFFICERIMEMBER EXCLUDED? N i NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 500,000 If yes,deserlbe under ..�__._..__. ..._,_ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) Operations typical to Commercial and residential electrical contractor. CERTIFICATE HOLDER woo CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Police Department w THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1475 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 '. ' AUTHORIZED REPRESENTATIVE Attention: Jonathan M.Samai ACORD 25(2009/09 C�1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 19 Dale Street Andover, MA 01810 Phone:978-475-4995 Andover Electric Services Fax:978-475-1.192 wire—it@comcast.net TO: FROM: Name: Town of North Andover Sender's Name: Robert J. Branca, President Attention: John Bonanno Company: Andover Electric Services, Inc RE: Police Department Date sent: April 7, 2014 Email: jbonanno@napd.us # pages including cover: Urgent For Review Please Comment Please Reply John, As discussed during our meeting, we are pleased to quote you for the following electrical work: 1. Unisex Bathroom: Change motion to switch. 2. Dispatch Bathroom: Change motion to switch. 3. 911 Closet: Take out motion, change to switch. 4. Main Electric Room (across from armory): Remove and replace switch. 5. Sally Port: Remove existing switches and install motion sensor. 6. Criminal Investigation: Furnish and install outlet for TV in ceiling. 7. Operations Division Commander Room 209: Furnish and install outlet for TV. Thank you for the opportunity to provide this quote. If you have any questions, or require any additional information, please do not hesitate to call me. Very,truly yours, Robert J. Branca President The Commonwealth of Massachusetts Department of Industrial Accidents Office of-Investigations 1 Congress Street, Suile .100 Boston, MA 02114-2017 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual'): Andover Electric Services, Inc. Address: 19 Dales Street City/State/Zip:Andover, MA 01810 Phone #:978-475-4995 Are you an employer? Check the appropriate box: Type of project(required): I. I am a employer with 5 4. n I am a general contractor and 1 6. FJ 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. n Remodeling ship and have no employees These sub-contractors have 8. F-1 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. n We are a corporation and its 10.❑ Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.n Other employees. [No workers' cornp. insurance required.] *Any applicant that checks box#I 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. lContractors 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. .1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:The Hartford -------- Policy 4 or Self-ins. Lic. #:08 WEC CM5940 Expiration Date:4/28/15 Job Sit'Address: 1475 Osgood Street City/State/Zip: No. Andover, MA 01845 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failu?c 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 Vc insur rage verification. Irpee I do hereby certify 7 l,�,e&underpain and penalties of perjury that the information provided above is true and correct Si ature: Date:May 14, 2014 Phone#: 97,8e4/7549 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 9 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#: FaK Then Detwh Mong An parkwaSons- ' ,r �j t rWJ r v Fold,Then 1JMch Along Ali — r l♦ r r y�y �� STATE.0E NEW HAM PSHIRE ELECY R191 lye BOARD NAME: 6 61�rIm A"r EXPIRES: 1 d