The URL can be used to link to this page

Home My WebLink AboutWire Permit - Permits #12642 - 1475 OSGOOD STREET 8/26/2014 ..... ............. .. .......... .......... .. ............. .......... -�� tt�i��IM1H��w'f�Y(��IMifllttilR�l Ellll6l(��ftil11N��III��RA(�fi�NIIItl��iM�QV�l�l6(IIIM��61��@(Q�%i(6��"C��UM1��SINVIII IM101M1l�tti�(��M(tt�II6i��NS64{�Ilil�tt(ii�((�S�/lN�i��V��QIII I�III�IhI IINI��Vf��ll�li ��(Wf��N (� 0(�ltt((("�IIN��//�'„(�(11i�1 �dG r; m , 7. M �.. p ? .....CIO � Ci d) b4d C14 „ rA O.t 41 %/ 1, ,:•.%/% ,.c. //// ,, / �,. // :_., � .ii �: i,/,./ ,,. //i, ,./ Official Use Only Permit No. [2--c-P +z- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS u,p [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: City or Town of: N01r I" An&Ovk-y' To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)147*5 p<xD Stye-jz* Owner or Tenant New"n Araby 'ToIi*%-Q�, 2Lxfc--e*rr--Q-"t Telephone No. Owner's Address 14 P�nCeADVtje, HA 018+-6 Is this permit in conjunction vWth a building permit? Yes ❑ No F±1 ' (Check Appropriate Box) Purpose of Building 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: <Z-c*virn <j- ,TQ,.x-r. vvo.,Lo5tAtj'Q" :Yi5todlo-fjon Completionoj'the fiollowingtable nM be waived by the lt!s ector(If Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Tf Above 1VOT-OTT—Mergency Lighting No.of Luminaires Swimming Pool grnd El grnd. F1 Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones TD— No.of Switches No.of Gas Burners N-o-.-o Initiatingetection and Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat um um r ors.......INA.......... N Localt❑ o.of Self-Contained Totals: /Alerting Devices No.of Dishwashers Space/Area Heating KW ion MunicipPl F1 Other CSvsteonnection ec y-9—uritms:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent np No.Hydromassage Bathtubs No.of Motors Total HP le ommunications wid No.of Devices or Equivalent OTHER: ba Attach additional detail if desired,or as required by the Inspector of 147ires. Estimated Value o Elect ical Work: 5co. (When required by municipal policy.) Work to Start: 15 61+ Inspections to be requested in accordance with MEC Rule 10,and upon completion. COVE INSURANCE CO VE AGE: 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 F] BOND F] OTHER F71 (Specify:) I cerdjy,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:G4A!±y LIC.NO.: Ilosl 3-A Licensee:W;Ilia*-ei T. 11 _Sig niaature L I C.NO.: (If applicable,enter -exe in the license number line.) lop' Bus.Tel.NoA0 r`1 ILL 61;,% Address: 10() Le—x MA,: T;rm i — '911*CLh 0 MA "7-1 g5 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,securitAhork requires Depahment of(Vublic Safety"S"License: Lic.No. P 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)n owner El owner's jtgent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 08/26/2014 11 :51AM FAX Z0005/0005 Please visit our web site at http://www.mass.gov/dpl/boards/EL GALAXY INTEGRATED TECHNOLOGIES I WILLIAM T MUISE (EL) 100 BIRMINGHAM PKWY BRIGHTON MA 02135-1118 Folil,Than Detach Along Ali ftdorallons o. commow LTH OF M MASSACHUS Woul. =910-1014111610=141=w �BOAMOF, ELE&RICIANS ISSUES THE FOLLOWING LICENSE AS A. REOSTtRED MASTER ELECTRICIAN 7jR GALAXY INTEGRATED TECHNOLOGIES WI LL I Ali-,T-440-1 S'E 100 BIRAINdHAK PKWY BRIGHTON MA 02135-1118 16814 A 1/11 58973 ME 08/26/2014 11 :53AM FAX [�0003/0005 The Commonwealth of,Massachusetts PrihtF6rrTir�7] Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/ContractorstElectricians/Plumbers ApWicant Information Please Print Lubly NaMe (Busintss/Organi7Ation/individual): 6fA\&.J-4 i e L Address: %00 I-ec> City/State/Zip: �r\ M�n Q�t-s�. Phone#: Lot U4-(PZZ'b Are you an employer?Check the appropriate box: Type of project(required): LJR I am a employer with q Z1 4. 0 1 am a general contractor and 1 6. M New construction 0_rnployees(full and/or part-time).* have hired the sub-contractors 2.[3 1 am a sole proprietor or partner- listed on the attached sheet. 7. [J 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.insuranceJ required] 5. 0 We are a corporation and its 10.Q Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their I I-Ll Plumbing repairs or additions myself.[No workers' cornp. right of exemption per MGL 12.n Roof repairs insurance required.)t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp, insurance required.] *Any applicant that checks box#1 must also fill out the section below showing ftir workers'cornponsation Policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractom most submit a new affidavit indicating such, tContractors 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'conWensatlon Insurance for my employees. Below is the policy and job site information. Insurance Company Name: (ShJC.,,r6 TVS,4rceme C.O. m. Policy#orSelf-ins.Lic.#: CaAuCS40%55 Expiration Date- ;i)'LAJ1% 14q:k sots-on Job Site Address:1415 ,,-City/State/Zip-.,&10�CA A^b o 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDIER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certyy u 2 that the_iq�ormadan provided above is true and correct f Date] L PhoncLL (oV1 - Off irse only. Do not write in this area,to he completed by city or town offtelftl City or Town: Permit/License At Issuing Authority(circle one); 1,ward of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 08/26/2014 11 :52AM FAX tgjvvv`lvvvo CERTIFICATE OF LIABILITYINSURANCE 826/DATE INSURANCE 241 lODK4 4 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(iev)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 confor rights to the certificate holder in lieu of such endomement(s). PRODUCER NONTA Construction Eastern Insurance Group LLC NE (508)651-7700 233 West Central. Street INSUMRM AFFORDINO COVERAGE NA1C 0 Natick MA 01760 INSURER A:Phil.adel hia Indamnit INSURED I $URER0 AmGuard 42390 Galaxy Integrated Technologies Inc INSURERC: 100 Leo M ,Birmingham Pkwy INSUReno, INSURER E Brighton MA. 02135 IN RF: COVERAGES CERTIFICATE NUMBER*MSTPR 2014.5 WC RENEWED REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE IN$URSD NAMED AIIOVE 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 I$SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPEOFINSURJINCE QUCYNUMBH 77KES LIMITS GENERALIJABIUTY UARENCE S 2,000,000 COMMERC)AL GENERAL UABILITY Ea Mom„ g 100,000 A CLA]MS.MADE �OCCUR BVK113062g Anyone arSon) 5 5,000 $k ADV INJURY a 2,000,000 AGGREGATE S 3,000,000 OCUL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A13G S 3,000,000 POLICY X PRO-JEL 1 LOG $ AUTOMOBILE LIAEULrTY COM�rnINGLE LIMIT l 00O 000 A ANY AUTO BODILY INJURY(Per perann) S AL_ OWNED SCHEDULED PMM1124303. 2/41/2014 /4/2015 BODILY INJURY Paracddeni) $ AUTOS AUTOS NON-OWNED Y` HIRSO AUTOS x` AUTOS PROPadRdem A E S X MO.DED X COMPJCOU_ S X UMBRELLA UAe X OCCUR EACH OCCURRENCE: $ 15,600,000 A Excess LIAR CLAIMS-MADE AGGREGATE~ $ 15,000,000 DED X RETENTION 10,00 �WM449008 /412014 /4/2015 4� B WORKERS COMPENSA1ION X TATll- ANDEMIPLOYERTLIARILM YIN I ER ANY PROPRIETOR/PARYNERfFXECUTIVfl 0 E.L EACH ACCIDENT Is 1,000,000 OFPICERIMEMOER EXCLUDED? NIA (Mandatory InNHI M=540855 /13/2014 /15/2015 E,L,DISEASE-EAEMPLOYE S 1 000 000 If yy4t doetY be under DESLLRIP'TIONOFOPERATION$twoW E.LDISEASE-POUCYLIMIT $ 1,000,000 A 1:11WFESSIONAL LUMIT,17Y aptcl i3at;23 /4/2014 /4/2015 FACH OCCURRENCE pl,000,000 AGGREGATE $1,000,000 DESCRIPTION OF OPERATION$I LOCATIONS I VEHICLE$(AtMen ACORD I OI.Addingtm ReMrka$chadul4,K more apaca tc rvauired) RE, HVIDENCS OF INSLTRANCM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TMC ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAIM THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS, 492 SUTTON STREET AUTNORIZJ D REPRtiSENTA FIVE NORTH ANDOVER, MA 01845 John KOagel/k14A -- _ ACORD 25(2010/05) m 1988-2010 ACORD CORPORATION. All rights reserved. IN&D2lt f7t11,Ml5101 The el:nRn n:%ma anrt Irvin ere raniatarnA m-54m of Al nVIN R/26/2014 5:28:06 AM PST (GILT-8) r!ROM: 10000;-TO: 19787093011. Paget 3 01: 3 IDATF(MiAlnbrmy) CC.PR AO CERTIFICATE OF LIABILITY INSURANCE =61�"26/2014 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 INSURI"R(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 forms and conditions of the pollry,certain policies may require an endorsement. A statement on this cartificelte does not confer rights to the certificate holder In lieu of such and6rsemeot(r)- OOWACT' PRODUCER EMPLOYERS INSURANCE GROUP INC _N81YIE-i PAX C/O EIGI OF NORTHEAST PRONE ALCRQ�EAffi_ _ JAL"D _ h 281 MAIN STREET SUITE 5 EMAI_L FITCHBURG, MA 01420 ADDRESS ;SSZ INSURER )AFl°GRDINd COVERAGE NAIL INaustm A: Llbefty Mutual FlIv Ins___ INSURED INSP131as 1 RESOURCE MANAGEMENT INC Es SURERC: 281 MAIN STREET SUITE 5 _ FITCHBURG MA 01420 NSUREKD: INSURER E: COVERAGES CERTIFICATE NUMBER: 2133384-1 REVISION NUMBER` THIS IS TO CERTIFY THAT T1-1112 PCLICI=.S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A130VE FORT1 IE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY RUOUIREMENT,TERM OR CONDITION OF ANY CONITPACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFSU(-'I-1 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDBY PAID CLAIMS. - PQLIQYr;FF Xy EXP LIMITS INSIR TYPE OF mAb INSURANCE POLICY NUMBER (MMIDD=l Ib/YYYYL LTR COMMERCIAL CIENGWIAI L_rry IASIL EACH OCCURRIENCIG 91CLAIMS-MADE F-10CCUR WED EXP An W5 00MMI_ S PERLONAL$ADV GEN'LAGGRIEEGATR LIMIT APPLIES PFR. GENERAL AQGRrGATP__ POLICY El stA& EILDC ±RODUCTS-COMP/OP AC: OTHER: COMPIRM SINGLE LIMIT AUTOMOF31LE LIABILITY frn n=ldrmt) DOOKY INJURY"-(P7'.;)__ ANY AUTO ALL OWNr D SCHEDULED FJ DOILY INJURY(Pir mccidarit) AUTOS AUTOS NON OWNED HIRED AUTOS AUT 8 EACH OCCURRENCE UM9RMLA UAB OCCUR OOUR EXCESS LIAR OCCUR AGORPOATP DED SET"ION$ -I- WC2-31S-365185964 3t2t2014 31212015- PERI-E POTR, A WORKERS CONIPSNSA710N AND EMPLOYERS'LIABILITY Y(" ANY FROPRIMRiPARTNERiFXrzCU_nVE G.L.EACH ACCIDENT 1000000 OPPICER)RAGMAPIR EXCLUDED? r, NIA _LL DISEASE-GA EMPLOYEE $ 1000000 (Windilloq in N") 11 EL,OIAEASP,POLICY LIMIT $ 1000000 R'3P T'lO�'J'O'P"O EFRATUNG[.I. DE9CRIPTION OF OPERATIONS/LOCATIONS/VEHICLES COVERS THE EMPLOYEES OF THE NAMED INSURED LEASED TO: BRA DLEY JONES D BA JONES A CO 97 DRUID HILL ROAD METHUENMA 018" This certifimte,cancels and supersedes-all previously Issued c,-)rI[I`icnInr,only as they relate to workors compensation oovernpe. Workers compensetIon Insurance Coverage applies only to the workers compensation IMWO of the state of M& CERTIFICATIE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVEF THE EXPIRATION DATF. THEREOF, NOTICr. WILL BE DELIVERED IN 1600 OSGOOD STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 0154'"i ALITHORIZIED REPRr-aCNTATIVF Lberty Mutual Fire Insurance 0 1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CSRT NO.1 21133 D 41 CLIENT CCIZIF; L365L8110 atin- ClipmdLer 0/215/2014 Ah'I (UT) POqQ 1 Of 1