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Home My WebLink AboutWire Permit - Permits #12913 - 723 OSGOOD STREET 11/13/2014 w Mi ME JIM- g� `\ ISBN& im ffit M owIBM\ Date... �,..:: .:.... ....... N MIMI 110 f;tyeMIk MM TOWN OF NORTH 0 PERMIT FOR WIRING \\ X, IN All g's *4#60 $ =+ice01 \ \\\ \ Jft 3 This Certifies that .._...... _.. ... ... ......_. _..._ ` NO has permission to perform .... wring in the building of ....MEN NO at o Andover, Mass. td __ ......�,.... � North d er, 111F IN Ex Few..go- . LAC. o �. ...... ... .. ...... . ...................................... � � IN ..... 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Location(Street&Number) 723 Osgood Street Map: Lot: Owner or Tenant Stevens Estate Telephone No.978-682-7072 Owner's Address same Is this permit in conjunction with a building permit? Yes [_1 No Z (Check Appropriate Box) Purpose of Building Conference Center Utility Authorization No. Existing Service Amps —Volts Overhead [_1 UndgrdE1 No.of Meters New Service Amps Volts OverheadF] UndgrdE:] No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Rewire garage lights and outlets Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures 6 No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above Ei In- Elo.of Emergency Lighting grnd. grnd. Battery Units # No.of Receptacle Outlets 4 No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches 2 No.of Gas Burners No.of Detection and V Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices <. Tons Na.of Waste Disposers Heat Pump N Totals. umber Tons I KW No.of Self-Contained . ................................................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Beaters KW Signs Ballasts No.of Devices or Equivalent No.Pydromassage Bathtubs No.of Motors Total UP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work $1,120.00 (When required by municipal policy.) Work to Start: 11/4/14 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 F-1 OTHER F-1 (Specify:) I certify,under the pains and penalties of perjury,that the information on this appl fi`i_s true and complete. FIRM NAME: Andover Electric Services, Inc =um LIC.NO.: 14302 Licensee: Robert J. Branca Signature LIC.NO.: *Per M.G.L.c. 147,s. 57-6 1,security work requires Deparlm6fit of P way"'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)F-1 owner F-1 owner's agent. Permit Fee: Owner/Agent Signature Phone: FP t9l cw,�A ACOR®e CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD7YWY) 04/28/2014 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 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 AMEACT Samel Insurance Agency,Inc. JONATHAN M SAMEL CIC LIA PHONE —FAXac No Ext: 978.474-0810 1"C N.): 978.474-0890 SAMEL INSURANCE AGENCY,INC. E-MAIL info�samel-ins.com _ 15 CENTRAL STREET ADDRESS: ANDOVER MA 01$10 PRODUCER CUSTOMER ID: 1254 INSURER(8)AFFORDING COVERAGE NAIC# INSURED INSURER A :Sentinel Insurance Co,LTD 11000 ANDOVER ELECTRIC SERVICES INC PO BOX 829 INSURER :Citation Insurance Company 40274 ANDOVER MA 01810 INSURER :Sentinel insurance Co,LTD 1100 INSURER D: Hartford Fire Insurance Company 19682 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 39153 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, CLUSIONS AND CONDITIONS OF qI IrH POI Ir.E.Q"MITS SHOWN MAY HAVE BEEN RE,)tJrFD BY PA n rJ All INSR TYPE OF INSURANCE ADD% SUBR POLICY EFF POLICY EXP LTR INSR M POLICY NUMBER MMIDD MMtDDIYYYY LIMITS A GENERAL LIABILITY 08SBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Esoccurence $ 1,000,000 CLAIMS-MADE I 0�OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 JGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG $ 4,000,000 POLICY X PROLOC $ MOaILE LfAaaITY KW7918 03/23/14 03/23/15COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident)BODILY INJURY(Per person) $ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ C X �EX7CESS LA LIAR X OccuR 08SBAIL4326 03/23/14 03123l15 EACH OCCURRENCE 2,000,000 I.U1a CLAIMS-MADE AGGREGATE $ 2,000,000 DEDUCTIBLE X I RETENTION $ 10,000 $ ® WORKERS COMPENSATION 08WECCM5940 04/28M4 04/20/15 X_ TORY LIMITS , O $TH y AND EMPLOYERS'. LIABILITY YIN ,.. __, ANY PROPRIETOR/PARTNERIEXECUTfVE E.L.EACH ACCIDENT500,100 OFFICERIMEMBER EXCLUDED? I� NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 500,000 If yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACbRD 101,Additional Remarks Schedule,If more space Is required) Operations typical to commercial and residential electrical contractor. CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 , ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: � Jonathan Same[ � ACORD 25(2009109) O 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 'a 1 Congress,Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia 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): 1.NO I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑,Remodeling ship and have no employees These sub-contractors have 8. C] 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1.1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *any applicant that checks box 41 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. 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'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:The Hartford Policy#or Self-ins. Lie. #:08 WEC CM5940 Expiration Date:4/28/15 Jab Site Address: 723 Osgood Street City/State/Zip: North Andover, MA 01845 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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the formm 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 coverage verification. I do hereby certify under the pains an"pe ties of perjury that the information provided above is true and correct. November 10, 2014 Si afore: °��" �" �-�� "� Date: Phone#: 978e=4754995 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#: FOK Shen Dahwh AWQ AN mdom'— �' ryfF"�^. �rr�#��'�s�w, f 'i .,.�4 a. 5•s rltr A S �� n4tlt Fold,Then Detach Mong AlA Pwfonffirm � {;r u ✓ Y#�'r � a d r { we STATE,0F NEW HAMPSHIRE ELECTRICANS BOAR® MAM"E: .R0 r� . 6 61 ':M a EXPIRES: 1 : a