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Home My WebLink AboutWire Permit - Permits #12914 - 430 OSGOOD STREET 11/13/2014 \\ f` Date ...... . . MI TOWN e TOWN OF NORTH AhIDOVE fl * - ' IT FOR WIRING `s ' 0 Min MW AN ' 1125 Certifies that Eft N - ........ ......... o ............... ............. .....: ------ - - -------.._.._. 23 his permission to perform01 4 ...................... o � IM 10 IN wiring in the building of a ............ _....... .... .. ....................._......._ ; \16at a ....... , North Andover, Mass. o Fte ° Lie No10 .... ......... �...�u.._ .r.. ......... __........._....._............................. �A\\ ELECTRICAL INSPECTOR g Gheck # \� � rommu0/G/ ;Al 1 I4 it IY 4r V t, I i az; cif (s », pay!i »iu» u,!rl, !!!INJJi!14111»'!1JI11,!gr», 11111, 11J; 1»�1�111 ll� �la��ll�lA� �J IJJJJJJI�, II�IJ1JJJl J�JJ i iii„n, �!iiii,�ii!u!i»»,�!„! �1JJJ" 11J111J10111911J1JJJJ�1JJlJJIlJJl1JJUJJ11J,1,WIlIII,�J1111��/��IJJIJJ�JJi��/JllllllJJll,,,��IJJ%%I �y��'yyii»ll'J�iIJ'��1J�iy1lJJ�"��11�e�JA11�JJa/Ilii�iviJ�J11�11�1111�J))J)lJlJl�lJ1IJ)1„J�Ji��i/J,i2,ill rJJ ,JJ ,�J�„ Commonwealth Of Massachusetts Official Use Only Department of Fire Services Permit Official Date Issued: BOARD OF FIRE PREVENTION REGULATIONS Eued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (PLEA All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 SE PRINT OR TYPE ALL INFORMATION) Date: November 10, 2014 City or Town of. NORTH ANDOVER To the Ins Of Wires: By this application the undersigned gives notice of his or her intention to perform the elecptricectoral work described below. Location(Street&Number) 430 Osgood Street Map: Lot: Owner or Tenant Town of North Andover — Owner's Address same Telephone No,978-794-1711 Is this permit in Conjunction with a building permit? Yes Ej No (Check Appropriate Box) Purpose of Building High School Utility Authorization Na Existing Service Amps -------- New Service Amps Volts Overhead Undgrd R No.of Meters Volts Overhead El Undgrd R No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replace pole light at entrance Com le ion Lf the.following table ma y be waived b the Ins ector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total No.of Lighting Outlets No.of Hot Tubs TransformersKVA Generators KVA No.of Lighting Fixtures Above Swimming Pool grnd. F� In- El Generators mergency ig fing No.of Receptacle Outlets No.of Oil Bur.ners rnd. Battery Units 4— FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Na,of Air Cond. Total Im iatin Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number� Totals: Tans...... KW No.of Self-Contained ........... of Dishwashers Detection/Alerfing Devices kp No Space/Area Heating KW Local [] Municipal i i El Other of ❑Dryers Connection Heating Appliances Key Security Systems: No.of Water KW No No.of Devices or Equivalent Heaters Data Wiring—: .. Si ns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: Na.of Devices or Equivalent Attach additional detail if*desir&4 or as required by the Inspector of Wires. Estimated Value of Electrical Work $2,570'.00 — (When required by municipal policy.) Work to Start: 11/14/14 Inspections to be requested in f INSURANCE COVERAGE: Unless waived by the owner,no permior the per formanceRule electriical of work maycompletion.issue unless the licen- see provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the pen-nit issuing office. CHECK ONE: INSURANCE Z BOND F-1 OTHER F� (Specify:) I certify,under the pains and penalties ofperjury, ❑that the information on M4_4101 PAr6don is true and complete. FIRM NAME: Andover Electric Services, Inc Licensee: Robert J. Branca LIC.NO.: 14302 Signature LIC.NO.: 0 u *Per M.G.L.c. 147,s. 57-6 1,security work requires Departmet" f P �� ety"S"License: LIC.NO.: S: (��applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 91 Address: 19 Dale St Andover MA Z,): 0 18 10 OWNER' Aft. UVANCI:i!:�WAIVER: I am aware that the li-e—ens-ee-Zoes not have the liability insurance coverage normally,Squired by law. By my signature below,I hereby waive this requirement. I am the(check one F�owner 0 owner's agent. Owner/Agent Signature I Phone: Permit Fee: A)A-i DATE (MMIDONYYY) AC R" CERTIFICATE OF LIABILITY INSURANCE 04/2812014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY O DNESATIVELY NOT CONSTITUTEMED, EXTEND ORA CONTRACTL TER BETWEEN THECTOHE GE By FORDED INSURER S), AUTHORIZED BELOW. THIS CERTIFICATE OF IN REPRES NTATIV R P DU Akin THP ERT F AT LD IMPORTANT: If the certificate holder s Cnn�A�DDITO ADDITIONAL INSURED, URED, the require an policyendorsement.$) must statement rSon this certificate doed. if es not WAIVED, rights to the 4 the terms and conditions of the policy, policies certificate holder in lieu of such endorsements CONTACT Samel Insurance Agency,Inc. PRODUCER Phone: (978)474-0810 Fax: (978)474-0890 NAME: AX 978-474-0890 PHONE A/C No: JONATHAN M SAMEL CIC LIA A/c No Ext: 978.474-0810 E-MAIL info@samei-ins.com SAMEL INSURANCE AGENCY,INC. AD RESS: 15 CENTRAL STREET PRODUCER CUSTOMER IIX 1254 NAIL# ANDOVER MA 01810 INSURERS) AFFORDING COVERAGE 11000 INSURED IN SURER A Sentinel Insurance CO,LTD 1 1000 ANDOVER ELECTRIC SERVICES INC INSURER B ;Citation Insurance Corn an 1100 27 PO BOX 629 INSURER :Sentinel insurance Co,LTD ANDOVER MA 01810 Hartford Fire Insurance Com an 19682 INSURER D: INSURER E _J 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 PERTHIS IOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,PETAIN, THE INSURANCE AFFION OF ANY CONTRACT OR OTHER ORDED BY THE POLICIES DESCRIBED OHEREIN IS SUBJECTPTOTALLOTHE(TERMS, CERTIFICATE MAY BE ISSUED OR MAY PE ADD'L SUER POLICY EFF POLICY EXP LIMITS NSR TYPE OF INSURANCE INSR wvD POLICY NUMBER MMIDO MMIODIYYYY 2,000,000 LTR A GENERAL LIABILITY OBSBAIL4326 03/23114 03123/15 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES(Ea occuren� .._------ X COMMERCIAL GENERAL LIABILITY MED.EXP(Any one person) $ 10,00 CLAIMS-MADE I X 1 OCCUR PERSONAL 8 ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 PRODUCTS-COMP/OP AGG $ 4,000,001) GEN'L AGGREGATE LIMIT APPLIES PER: $ PRO- LOC POLICY X COMBINED SINGLE LIMIT $ 11000,000 AUTOMOBILE LIABILITY KW7918 03/23/14 03/23/15 (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 $ OBS13AIL4326 03/23/14 03123/15 EACH OCCURRENCE 2,000,000 (� X UMB REL LA LIAR X OCCUR 2,OOD, 00 AGGREGATE ExCESS LIAO CLAIMS-MADE _ DEDUCTIBLE $ X RETENTION $ 10,000 OTH $ D WORKERS COMPENSATION 08WECCM5940 04I28C1.4 04/2$/15 X., TORYu,ITS - ----- AND EMPLOYERS' ,LIABILITY YIN-- E.L.EACH ACCIDENT 500,000 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? I N I N I A E.L.DISEASE-EA EMPLOYEE 500,000 (Mandatory In NH) Ify98,d8",J,sunder E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below - - Schedule,DESCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks S ,If more space is required) Operations typical to commercial and residential electrical contractor. iIF y CERTIFICATE HOLDER CANCELLATION i i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE " Town of North Andover r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street a ACCORDANCE WITH THE POLICY PROVISIONS. T North Andover,MA 01845 _ �. AUTHORIZED REPRESENTATIVE i y Attention: Jonathan M.Samel i ACORD 25(2009109) 0 988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i The Common wealth of Massach usetts .Department oflndustria/Accidents A Office of Investigations �' t a w 1 Congress Street, Suite 100 Boston,MA 02114-2017 Workers' Compensation Insurance Affidavits Builder A licant Informat>Eon s/Contractors/Electricians/Plumbers Please Print Le ibl Name (Business/organization/individual): Andover Electric Services, Inc. Address: 19 dales Street City/State/Zip:Andover, MA 01810 FAreou an em to er. Check the a ra rate box: Phone #:978-475-4995 P YPP PI am a employer with 5 4. I am a general contractor and I Type of Project(required): 2.❑ employees (full and/or part-time).* have hired the sub-contractors 6• ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees These sub-contractors have R Remodeling working for me in any capacity. employees and have workers' g' ❑ Demolition [No workers' comp. insurance camp, insurance.: 9. ❑ Building addition 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 myself. [No workers' camp. right of exemption per MGL 1 Plumbing repairs or additions insurance required.] t c. 152, §1(4),and we have no 12.❑ Roof repairs employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also HIl 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 indicatingsuch. 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 mr employees. Below is the policy and jolt'site information. Insurance Company Name:The Hartford Policy#or Self-ins. Lic. #:08 WEC CM5940 Expiration Date:4/28/15 .rob site Address: 430 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 form of a STOP WORK ORDER Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off and a fine Investigations of the DIA for insurance coverage verification. ice of d du hereby cert{/y under the pains and altztis o06jury that the anformataonprovuled above is true and correct.Signature: November 10 2014 '" Date Phone#: 978-479: 995 .. ... ..... ... .._.__ Official use only. Do not write in this area,to he completed 6 p y city or town official. r 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#: m IV t FOK Then Debich Aloft AN PerforadOnS a I Fold,Thorn Dotrach MOM Afl IPerfasratirnn� t + 17 oN J + }9 �r r, STATE,0F NEW i4AMPS"'RE IELECTR{C S BOARD o NAME: R J � 661P,P-) I , u: EXPIRES.:Pill 1� i j i i