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Commonwealth of Massachusetts Offilial Use Only
Department of Fire Services Permit No.
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: March 11, 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 El No Z (Check Appropriate Box)
Purpose of Building Football Field Utility Authorization No.
Existing Service Amps Volts Overhead I Undgrd No.of Meters
New Service Anips Volts Overhead 7 Undgrd 7, No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Repair football field feeders
Com letion o the,'llowing table may be waivedInspector of Wires.
No.of Recessed Fixtures 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 MSwimming Pool Above E] In- F, No.of Emergenc—y—Ligbting
grnd. grnd. Batter Units 17
'r y Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
2
No.of Switches No.of Gas Burners No.of Detection and ell
Initiating Devices
No.of Ranges No.of Air Cond. Total_ No.of.Alerting Devices
No.of Waste Disposers Heatpump Tons
:Tqq� I KW No.of Self Contained
Totals-
....... Detection/Alerti Devices
No.of Dishwashers Space/Area Heating KW Local n Municipalw.
M Other
Connection
No,of Dryers Heating Appliances KW Security
No.of—Water No.of ivalent
KW INO.of No.of Data Wiof ring:
Heaters �ns Ballasts No. Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER: Repair 600 MCM feeder from high school to concession stand
Attach additional doad—ifdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work $3,100.00 (When required by municipal policy.)
Work to Start: 3/4/14 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- "T"
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.
(N
CHECK ONE: INSURANCE ED BONDE] OTHER F] (Specify:)
I certify, �
y,under the pains and ofperjury,that the infi)rmadon oil d1l's(IR *'adon is true and complete.
the "I"P
......rma'io"0."l"i"
FIRM NAME: Andover,Electric S�jryLrces, Inc
LIC. NO.: 14302
I n
Licensee: Robert 1."Branca Signature. LIC.NO.:
*Per M.G.L. C. 147, s. 57-6 1,security work requires Departa t of blic Sa "S"License: LIC.NO.: S:
(Ifqpplicable, enter "exempt"in the license number line.)
Address: 19 Dale St Andover, MA Zip. 01810 Bus. Tel.No.:._,278-475-4995
Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I a' --27-8-423-8350
in 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)El owner 0 owner's agent.
Owner/Agent Signature-----.----_.----Phone:__--.-- Permit Fee:
v\-)
ZA211,
c '_I,, �r,, v"y)(J"" t,
DATE (M D'—)
E 'm=02/04"/204
CERTIFICATE OF LIABILITY INSURANCE 02/04/201'4
THIS CERTIFICATE IS ISSUED AS AMATTER 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
IREPHEIgENIMIVE 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 andorsoment(s).
=T
PRODUCER Phone: (978)474-0810 Fax: (978)474-0890 EACT Same[Insurance Agency,Inc. —
JONATHAN M SAMEL CIC LIA 978-474-0890
'C No, -0810
_Extj: 978-474
SAMEL INSURANCE AGENCY,INC. E-MAIL info�Samei-Ins.cam
15 CENTRAL STREET PRODUCER 1254
SMEOMER to
ANDOVER MA 01810 —
INSURER(S) AFFORDING COVERAGE __..XAIC#
INSURED INSURER A Maryland Casualty Company 19356
ANDOVER ELECTRIC SERVICES INC INSURER 0 Citation Insurance Company 40274
PO BOX 629 INSURER C National Union Fire Insurance Co of
ANDOVER MA 01810 INSURERD' Commerce and Industry Ins Co
INSURER E
INSURER F
COVERAGES CERTtFICATIE k6kilift: 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,
F4rl I Isi NR AND rONDITIO R OF SUCH P E&L MITS SHOWN MAY HAVE BEEN REIN jcFn BY PA n Q AIMA
!N8R I ADD'L SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE INSR WVD —Y......POLICY NUMBER _MMqDNYYY fMWDLM_YJ_
A GENERAL LIABILITY CFP016027733 03/23/13 03/23/14 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISE (Ea occuren l $
CLAIMS-MADE I X OCCUR
D.EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIESPER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY EK PRO- 7LOC $
B AUTOMOBILE LIABILITY KW7918 03/23/13 03/23/14 COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
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 $
$
C X UMBRELLA LIAR xFOCCUR ESU037051867 01/20114 01120/15 EACH OCCURRENCE $ 11000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE 1,000,000
DEDUCTIBLE $
RETENTION S $
WC D WORKERS COMPENSATION WC9763814 04/28113 04/28/14 X TORYLISTATU-
MTS
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNEPJEXECUTrVE E.L.EACH ACCIDENT $ 500,000
OFFICEPJMSMISER EXCLUDED? L N/A
(Mandatory In NH) E.L.D 5,00 DISEASE-EA EMPLOYEE "000
If y..,d.—Ib.-de,
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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
120 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
North Andover,MA 01845
AUTHORIZED REPRESENTATIVE
Attention:
Jonathan M.Samel
ACORD 25(2009/09) 0 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department oflndustrldAccidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass gov/dla
Workers' Compensation usiturance Affidavit: Buliden/CantractoltiVElectriciaus/Plumben
Agpligall,Information e Print Lejziblv
Name(business/Orpnization/lndividum)•Ardover Electric Services,Inc.
Address:19 Dale St
City/State/Zip;Andover, MA 01810 Phone#;978.475 4908
e. .
Are you an amproyi, Check the 4li0 0 box: Type of project(required):
1,❑ I am a employer with 4. [;] I am a general contractor and I 6. rl New construction
employees(full or part:ti ).* have hired-1he listed on the attached sheet. "N"` Rem
2.❑ I am a sole proprietor or parbner-
odeling,
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' Building addition
[No workers'comp.insurance Comp. insurance.: 9.
required.] S. We are a corporation and its 10.M Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 l.n Plumbing repairs or additions
myself.[No workers' comp. right of exemption per 1VtK 4 12.Q Roof repairs,.
insurance required.]t c. 152, §1(4),and w 6 have no
employees. [No workers' ME-1 Other
camp. insurance required.] ,
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infotrnedion.
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors trust submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors aiid state whether or not those entities have
employees. if the sub-contractors.have employe,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation tnfar►nattan. insuurance far my ei playeex helow!s the paltry and Job site
Insurance Company Name:Hartford Insurance Group
Policy#or Self-ins.Lic.#:08WECCM5940 Expiration Date:4/28/14
Job Site
'ty
Address. �- � �� ._Ci /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 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 tine
of up to$250.00 a day against the violator, 'e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurer c erage verification.
I do hereb cent under the d enarltics a jury that the to rrnation provided above is true and correct
Signatu
Phone y". C
Of,ylcial use only. Do not write in this area,to be completed by city or town official
City or Town: "`y`
Permit/License#
issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
M z I ,
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