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Home My WebLink AboutWire Permit - Permits #12907 - 1475 OSGOOD STREET 11/12/2014 gg- UH = = \ .... ..... ..... . IONIC NINE NOR Date .. WN IN ED Mki 0 �\ \\ \f rHTOWN No 01 1101 ELFIRING DERMIT FOR 'A BEENSRI 11 * ,a .., ,` SEND p°;.Te ' NO NINE \\ hwi 'Ig 01 Al s \i — Ew This certfie t INE ME u at - . \\ IN WIN �R ero� .,. has permission to . ..... ggp, �v�r�ng In the building omrsf = \\ _ .,... .... Forth Andover, ass at £ � � \\ :, ._®. NV.. OR KE Fes. At _ \ pg I BEEN NEW INE IS heck# OWNERS IN \\ M, Commonwealth of Massachusetts Official jUe Only Permit No. I Department of Fire Services 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(ME '),5 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector 6' Tfires., By this application the undersigned gives noti e ofh* her intention to perform the electrical work described below. Location(Street&Number)—A(2'5 1!� 15 7-- Owner or Tenant 5 Uzi" Telephone No. Owner's Address Is this permit in conju ion with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building !5'&Z;";I Utility Authorization No. Existing Service_ Amps Volts Overhead El Undgrd El No.of Meters New Service Amps Volts Overhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Al2pt yo —47 Locatio and Nature of Proposed Electrical Work: A"4 92,) 72> Completion of the.followins,table may be waived by the hvVNctor o Wires. et 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 No.of Luminaires Swimming Pool Above o In- r-1 0.of Finergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices No.of Ranges Na.of Air Cond. Total No.of Alerting Devices Tons W, No.of Waste Disposers Heat Pump number Tons I.K. .W No.of Self-Contained Totals: I Detection/Alerting Devices E] Municipal No.of Dishwashers Space/Area Heating KW Local Connection 0 Other No.of Dryers Heating Appliances KW Security Systems:' No.of Devices or Equivalent No.of Water No.of No. of Data Wiring: Heaters KW Shins Ballasts No.of Devices or Equiva ent No. Hydromassage Bathtubs No. of Motors Total HP T-elecommunications Wiring:No.of Devices or Equivalent IOTHER: Attach additional detail if desired, or as required by the Inspector of Wires. xF Estimated Value of Ejectrjcal Work: J!&Loa (When required by municipal policy.) Work to Start: 1111P115( Inspections to be requested in accordance with M EC Rule 10, and upon completion. INSURANCE C(jVEIkA(;E: 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 El (Specify:) I certify,under the pains and penalties of perj ury,that the information on this application is true and complete. FIRM NAME: f GA.- 00*- LIC.NO.: Licensee: Signature 0i LIC. NO (If applicable,enter "exen7pt in I e It ense number line.) Bus.Tel.No.. Address: Alt.Tel.No.: *Per M.G.L c. 147, s. 57-61,security Work requires Department of Public Safety "S"License: Lie.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)F—Iowner El owner's Qgent. Owner/ALent Signature' Telephone No. PERMIT FEE: $&Ar�4) The Commonwealth of Massachusetts Department ofIndustrialAcchlents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (BL]sitiess/Ot-gai)izatioti/IndividLl',11): J.M. Electrical Company, Inc. Address:Six Kimball Lane, Suite 320 City/State/Zip:Lynnfield, MA 01940 Phone #: 781-581-3328 Are you an employer? Check the appropriate box: Type of project (required): I.RE I am a employer with 99 4. ❑ I arn a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.0 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. F❑ We are a corporation and its 10.(1 Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their I LF Plumbing repairs 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 13.17� Other employees. [No workers' comp. insurance required.]. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, t 110111COWnCrS Who submit this,,iflidavit indicating they are doing all work and then hire Outside contractors must submit 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 i vorkers'compensation insu ran ce for ni�v empl(aIlecm Below is the police anal Jab site information, Insurance Company Name:Continental Western Insurance Company Policy 4 or Self-ins, Lic. #:WPA-5124326 Expiration Date: 1/1/15 Job Site Address: City/State/Zip: 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 Lip 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 covet-age verification, I(to here certif�under thepains andpenaltles of perjury that the information provided above is true and correct. Dat e: Phone 4: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 4 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 4: ,q,tICQJgj�► OP ID: CD w.---- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE7R,1 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 an this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER Phone:781-935-8480-NAME. t:r DeSanctis Insurance Agcy,Inc. 100 Unicorn Park Drive Fax:781-933-5646 PHONE Fax Woburn,MA 01801 E-MAIL ac aDDRESS.;� PRODUCER _.---.-...._�....__.........,—._._...,-_�_ R a:JMELE-1 INSURED J.M.Electrical Co.,Inc. ._...—.._...��....�. �.. .---- --. INSURERS AFFORDING COVERAGE..__._..._ NAIL 11 INSURERA:Acadia Insurance Company Six Kimball Lane,Suite 320 - — P INSURER B:Llo ds of London Lynnfieid,MA 01940 _ Y INSURER C:Continental Western --_ INSURER D INSURER E� COVERAGES INSURER F 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR —.._._.... -. ._. Tit TYPE OF INSURANCE PgLCU Y EFF POLICY XP -- POLICY NUMBER MM/OD/YYYY MM/D /YYYY LIMITS — GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CPA010106Q20 01/01114 01/01/15 [SAMAGEY0fif79 �S..___ — _ CLAIMS MADE J OCCUR .-MMI E (Ea occurrence) $—�— 250,00 MEO EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ — 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: ----------� _. POLICY X PRO- LOC PRODUCTS-COMP/OP AGG $ 1,000 00 JECT AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,00 -._.... -- —__ ALL OWNED AUTOS BODILY INJURY(Per person) $ X SCHEDULED AUTOS MAA01 0350220 01/01/14 01/01/15 BODILY INJURY(Per accident) $ —_ _X HIRED AUTOS PROPERTY DAMAGE ---X NON-OWNED AUTOS (Per accident) $ X UMBRELLA L1A6 X OCCUR $ A Excess uAa EACH OCCURRENCE $ 10,000,00 ... _..`..._.._ CLAIMS-MADE DEDUCTIBLE CUA010350320 01/01/14 01/01/16 AGGREGATE $ 10,000,00 RETENTION WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY WC STATU- OTH- C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WPA5124326 I 01/01l14 01/01/15 X DEYLIMILi - _.E OFFICER EXCLUDED? l •• � N/A E.L.EACH ACCIDENT $ 1,000,00 (Mandatory in NH) MA — — N yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,OQQ,QQ DESCRIPTION OF OPERATIONS below --— — B Prof Liab 81230FF00032A13 E.L.DISEASE-POLICY LIMIT $ 7,000,00 01/01/14 01/01/15 Prof Lim A Install Floater CPADIO106020 01/01/14 01/01/16 IF Limit 700,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space la required) 250,00 Evidence of Coverage CERTIFICATE HOLDER CANCELLATION TO WHOM FSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TO WHOM IT MAY CONCERN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009l09} The ACORD name and logo are registered marks of ACORD