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Home My WebLink AboutWire Permit - Permits #12150 - 430 OSGOOD STREET 2/7/2014 V' wim MKIN MEN "g \� � Date...... . .................................... MIAMI NOW- IN TOWN OF NORTH ANDOVER 10 ME A � \ 0wA gwmi 1:111 IN rPERMIT FOR WIRING \ \\ HU . ��- T s certifies that ., ,,..:.,.. � �� ...,.. ........ .... . 9 �. c affil \\ has permission to petfti � ........ .......,a ......... ,.._.....�.......� ......,.. ...� . ..........,.... warn in the building o o g ............................................................ 0 �\ .. . ini at ........................... ..: � .,........a�... _�� .. . Forth Andover, Mass. �\ SEE SRI pull Fee.....,... e .......... Lac, No ..,,.. E.�.,:.. � ..�.: : .. „ .. :. � ` ELE ICALQINSPECTOR ;o Check# _P f1f,IS \\ ME BMW � , If!, i. ti H I I U u l ! ! II !7 11 I I 1 J I 1 J J JJJ Y I 1111 1 17 1 1! 1 1 J I111 11, rll I l J1JJ1 1 r n i I 1 II11u1 I1J ll�l �� I� J>>1�� J »llI�JIJJ�J1/1J 1J JJJ J n , 1J11JJ11A,J 11 Jl�JIJJJJ JJJJ1,llI ,J, l, 1JJJ22 l� )11, �1 1 ) )J J)))llJ,1 1 JJJIJIJ l��Jl JJJJJl1 JJJJJAll1lJJJlJI/�/Jr%lllllllJl/rJJJl1JJJ J.JJJ �J�aJJ JJJrJJJ;J JIJJ�II//l�JJ11J,,,)JJil�lJll�J,��JJ �/�J� Commonwealth of Massachusetts Official Use Only T) Department of Fire Services Permit No. 2 BOARD OF FIRE PREVENTION REGULATIONS Date Issued: 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: February 4, 2014 City or Town of: North Andover 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) 430 Osgood Street Map: Lot: Owner or Tenant - North Andover High School Telephone No. 978-794-1711 Owner's Address same Is this permit in conjunction with a building permit? Yes [—I No Z (Check Appropriate Box) Purpose of Building Football Field Utility Authorization No. Existing Service Amps Volts OverheadF_1 Undgrd FI No.of Meters New Service Amps Volts Overhead ❑ UndgrdO No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Football Concession Stand Comp/ lion o 'the following table may be waived by tite Inspector of Wires. No.of Recessed Fixtures I 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 o in- No.of Emerg5cy Lighting gr,d. 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 ................. _.J.K.W............ No.of Self-Contained Totals: ..... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local E] Municipal 0 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 I Si2ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent THER: Re air 600 MCM feeder from hi h school to concession stand Attach additional detail y desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work $2,900.00 — (When required by municipal policy.) Work to Start: 2/6/14 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 [D BOND F] OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the informal S application is true and complete. FIRM NAME: Andover Electric Services, Inc LIC. NO.: 14302 Licensee: Robert J. Branca Si tore LIC.NO.: �P ,� *Per M.G.L. c. 147, s. 57-61,security work requires D�partment of Public Safety"S"License: LIC.NO.: S: (If applicable, enter "exempt"in the license number line.) Address: 19 Dale St, Andover, MA Zip: 01810 Bus. Tel.No.: 278-475-4995 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 by law. By my signature below,I hereby waive this requirement. I am the(check one)r-1 owner F-1 owner's agent. Owner/Agent Signature--------..-.-----Phone:-- Permit Fee: --.- DATE (MMIDO"Y""'D CERTIFICATE OF LIABILITY INSURANCE o204n014 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(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 endonsement(s). PRODUCER CONTACT Phone: (978)474-0810 Fax: (978)474-OB90 NAME: Samel Insurance Agency,Inc. JONATHAN M SAMEL CIC LIA �%CP'� . FAX C, F.,): 978-474-0810 11 No: 978-474-0890l SAMEL INSURANCE AGENCY,INC. =gs: lnfo@samel-ins-com 15 CENTRAL STREET PRODUCER ANDOVER MA 01810 CUSTOM R ID; 1254 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A Maryland Casualty Company 19356 ANDOVER ELECTRIC SERVICES INC INSURERS Citation Insurance Company 40274 PO BOX 629 INSURER C National Union Fire Insurance Co of Pittsburg ANDOVER MA 01810 INSURERD: Commerce and Industry Ins Co INSURER E INSURER F COVERAGES CERTIFICATE NUMBER.: 38483 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, rl I JSIONS AND CONDITION-,OF SllakLe MITS qHOWN MAY HAVE RFFN RED1 ICED BY PA D r!AIM& INSR TYPE OF INSURANCE ADVIL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INISR WVD iMMIDDNM) _ARM94N_M__L_ A _GENERAL LIABILITY CFP016027733 03/23/13 03/23/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMI 6A—MAGE TO RENTED SES(Ea occurence) $ — CLAIMS-MADE I X l OCCUR MED.EXIP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY [K PRO. LOC $ IFrT 7 8 AUTOMOBILE LIABILITY KW7918 03/23/13 03/23/14 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 — ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ M $ C X UMBRELLA LIAR X OCCUR EBU037051867 01/20114 01120/15 EACH OCCURRENCE $ 1'000,000 EXCESS UAS CLAIMS-MADE AGGREGATE $ 1,0001000 DEDUCTIBLE $ RETENTION $ $ D INORKER8 COMPENSATION WC9763814 04/28/14 X TORY LIMITS OTH $ AND SMPLOYERV LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETORIPARTNERIEXECUTrVIE OFFICCRIMSMBER EXCLUDED? [7N MIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ ......S'00"00W If Yee,do—ib.under -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below E.L.DISEASE 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St L ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Attention: /% y ..a P Jonathan M.Samel ACORD 25(2009/09) C 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 ir I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Andover Electric Services,Inc. Address:19 Vale St Ci /State/Zi :Andover, MA 01810 Phone #:978-4754995 Are you an employer?Check the appropriate boas Type of project(required): 1.® I am a employer with 5 4. [] I am a general contractor and I 6. ®New construction employees(full and/or part-time).* have hired the sub-contractors 2,[] I am a sole proprietor or partner- lasted on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' camp.insurance comp• insurance.$ required.] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I L 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 (� Other employees. [No workers' L camp. insurance required.] *Any applicant that checks box#1 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. ;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.1.11 I 11 f the sub-contractors have employees,they must provide their workers'camp.policy number. I fo an employer that is providing workers'compensation Insurance for my employees. Below is the policy and f ob site information. Insurance Company Name:Hartford Insurance Group Policy#or Self-ins.Lic.#:08WECCM5940 Expiration Date. .4/28/14 Job Site Address: ;µ . `C ity/State/Zip: Attach a copy of the workers'compensatid 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 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 f ins ce coverage verification. I do hereby cert.cert.Ty un th ns and penables aker L 2 that the rmation provided above is true and correct t a e• Phone#: FOfflelal use only. Do not write in tAh area,to be completed by city or town ofJtcial y 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#: 1 b ay IRI1? 1 R • J yF•�J Fd /�, 4/ ,��.yyy��,�� S !` f WfJ l� 1 y+ .�y�,cy.,.Jf• .1' r. 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