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Home My WebLink AboutWire Permit - Permits #12952 - 430 OSGOOD STREET 12/1/2014 Date ` _ ... \\ \ \ ND R NEW RTFr NORTH A OF \ ; TOVVt KIM WIN \\ 101 \ \ U, UN JIM6 `�+sic #tom _ ON : . x E is certifies that .,. ,.,. .......IN 1011 , _�._�_.. T an to perf� 4 has ernnssl ....... ........ wiring to the building Qrth Andover, ass \ o �\ \\ at ......... \� Ec rIyCALSp I�t cTox \ Fee,,.. 4# ,pgmr , ..., . Lic. c . .. ,..°,... ` pm � r beck oWEIRD � \ INNER .: EmN12/01/2014 11:34 FAX 978 475 1192 ANDOVER ELECT U001 Commonwealth ofMasisachusetts Official US_1:6nly Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Date Official APPLICATION FOR PERMIT TO PERFORM ELECTkICAL WORK All work to be performed in accordance,with the Massachusetts Electrical Codc(VIEC),527 1:&M 111.00 (PLEASE PRINT-12V EVK OR 2YPE ALL INFORMATION) Date:— November.24, 2014 City or Town of. NORTH ANDONTR TO the Inspector of If iires.- BY this application the undersigned gives notice of his or,her intention to perform the electrical work descT i bed be.!Iow. Location(Street&Number) 430 Osgood Street Map: Lot: Owner or Tenant North Andover High School Owner's Address same N i i,978794 1 711 Is this permit in conjunction with a building permit? Yes ❑ No Z (Check Appropi late D ox) Purpose of Building High School Utility Authorization l�ro.-___ Existing Service Amps �Volts OverheadO Undgrd 0 No.of 1%1 eters New Service Amps -volts Overhead Undgird L1 No.of its eter.3 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W' iiring of split A/C unit in IT Room Vt floor Com lefign qL the fedlowinli-table may be waived b the Inspector of Wires. the o`�waived 0 ' No.-,,of Recessed Fixtures No.of Ceil,Suspl,(Paddle) of Total .�addle)Fans Transformers KNA 00 No.of Lighting outlets No.of Hot Tubs Generators It VA No.of Lighting Fixtures Swimming Pool - LAbove In-— El o.o mergency ig ti—ng Ind. grnd. Battery Units No.of Receptacle Uutlet, No.of Oil Burners FIRE ALARMS No of Zones No.of Switches No.of Gas Burners ofDetectFio-and Initiating Devices No.of Ranges No.of Air Cond. To el No.of Alerting Devices No.ofWaste Disposers Heat Pump Number Tons XfW No.o J, Totals DetectionlAlerting Devi;es No.of Dishwashers Space/Area Heating KW ]Local F1 Municipal Connection 0 Other No.of Dryers Heating ApplianCes ]KW Security Systims: No.of Water KW NO.of No.of Devices or Eqj!Livsilei it Heaters Signs Ballasts D No.Hydromassage Bathtubs No.of Motors Total UP Telecommunications Wiring: OTHE No.of Devices or Ea uivalent Attach additional detail ifdesireir or as required by the Inspector of Fr-es, Estimated Value of Electrical Work _$1,810.00— (Mien required by municipal policy.) Work to Start: 11/24/14 Inspections to be requesred in accordance with MEC Rule 10,and upon cc t r1pledon. INSURANCE—COVERAGE: Unless waived by the owner,no permit for the performance of,electrical work may tissue unless the licen- see provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. Ille undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND E] OTHER 0 (Specify:) I certify,under thepains and pen, ofperjury,that the informatto n this application is true and comp fete_'06 FIRM NAME: Andover Electric Services. Inc Z LIC.NO.; 113-02 Licensee: 'Robert J. Branca —_ Signature LIC.NO�: *Per M.G.L.c. 147,s.5 7-6 1,security work requires Depanne, is Safety"S"License: LIC.NCI.: S: (If applicable, enter "exempt"in the license number line) i Address. aware-J 9 Da St, Andover, MA Zip., 01010 Bus.Tell.No._- _VA-AZi-A225_ OWNER'S INSURANCE WAYVWAIVER: I aura aware Tel. at the Licensee does not have the liability insurance coverage norm&ly requ ired by law. J$y MY signature below,I hereby waive this requirement I am the(check One)[:1 Owner 0 owner's agent. Owncr/Agent Signature Phone; I—Pcimit Fee: 12/01/2014 11:35 FAX 978 475 1192 ANDOVER ELECT 002 The Comnum-wealth of Massachusetts Department of IndustrialAccidents '15 Of, of Investigations IR I Congress Street, Suite 100 Boston,MA 02114-2017 Tj k., wwjv.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrii-iani&,'Plumbers Ple se Print Legibly Applicant Information Name (Business/Organization/ladividual): Andover Electric Services, Inc. Address: 19 Dales Street City/State/Zip.Andover, MA 0 1810 Phone #:918-475-4995 Are you an employer? Check the appropriate box.* Type of prc i ect((required): 1.IN I am a employer wi tb 5 4. [:] I am general contractor and 1 6. L]New --onsiruction employees (full and/or part-time).'* have hired the sub-contractors listed on the attached sheet. 7. ❑Remcdeling 2.Lj I am a sole proprietor or partner-ship and have no employees These sub-contractors have 8. Demoliti011 working forme in an employees and have workers'y capacity. comp. insurance.t 9. r] Building addition [No workers' comp. insurance 5. We are a corporation and its l(IF1 Elect-Ical:mpairs or additions required.] 3 0cers have exercised their I I..n plurri,ing repairs or additions I am a homeowner doing all work offi myself (No workers' comp. right of exemption per MOL l"I.F1 Roof repairn hisurance required.] t 0. 152, §1(4),and we have no I 3.Lj Othel employees. [No workers' cornp. insurance required.] *Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information I Homeowners who submit this affidavit indicating they ve doing all work and then hire outside contractors must submit a new i fficlavic indicating such. ;Contractors that check this b"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 cmployocs,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below Is thapoik-y and job site information, Insurance Company Name:The Hartford 08\A/EC CM5940 -4/2606 Policy 9 or Self-ins. Lic.#: Expiration'Date.__.__ Job Site Address: 430 Osgood Street City/State/Zip: No,,ArK-lover, 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'%QR.K ORDER and a fine of up to$250.00 a day ainst the violator. Be advised.that a copy of this statement may be forwardec to the Office of Investigations of the IA for insurance coverage verificalion. I do hereby ce r the and of perjury that the Information provided above is to and correct rdff und,tag '14, 2014 November ,. 5ignature: I Date: Phone M 7, 995 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 4 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. Cityffown Clerk 4.Electrical Inspector S.M timbiing Inspector 6.Other Contact Person: Phone#-. 12/01/2014 11:36 FAX 978 475 1192 ANDOVER ELECT Z003 DATE (MMIDONM) CiORO' CERTIFICATE OF LIABILITY INSURANCE 04/2 812 01 4 RIGHTS U1PONTkE(',VRTIF11CATE MOLDER-THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO IC OR ALTER THE COVERAGE AFF1:1lRDED BY THE POLICIECS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND BELOW. THIS A CONTRACT BETWEEN THE ISSUING IIISURIER(S), AUTHORIZED 3ELOW. 7HIS CERTIFICATE OF INSURANCE DOES NOT coiNisTITUTE .�, �R REPRESENTAIINE OR PRODUCER,AL THECE F1 AT LDER. IMPORTANT: if the cortifloste holder to an ADDITIONAL INSURED. that POICY(Ifts) must be endorsed. If SUBROGATION IS WAIVED, atit-jW to the terms and conditions of the policy,certain policies maY require an ondarsament. A statement on this certificate dogs not conFe y rights to the certificate holder In lieu of such endorsement($). PRODUCER Mona: (97B)474-0610 Fax: (916)474-0890 CONTACT Samot Insurance Agency,Inc. 978-474-0890 PHONE 978-474-0810 16C_N6L.'. JONATHAN M SAMEL CIC LIA SAMEL INSURANCE AGENCY,INC. i S CENTRAL STREET ANDOVER MA 01810 INSURER($) AFFOMNIG_COVERAGE.____ NAIL INSURER 8 Sentinel Ineurance Co�LTD 11,1000 — INSURED ANDOVER ELECTRIC SERVICES INC jNqU;tgIj a Citation Ineurance Company 40274 P0 BOX 629 INSURER C Sentinel insurance Co,LTD 1100 -- ANDOVER MA 011810 IN3 RO, Hartford Fire Insuranc_Coma m_ lee — INSURERS INEVAER F REVISIONINLIOlaER- CER11FICATE NUMBER: 39153 POLICY PERIOD COVERAGES NAMED ABOVE: FOR THE P THIS IS To CERTIFY THAT THE POLICIES Or INSURANCE LISTED A 2LOW HAVE BEEN ISSUED TO THE INSURED NA NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wrw RESIPI!OT To WHICH THIS INDICATED, DESCRIBED HEREIN I$ SU.IJECT _10 ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES M I IMONS AND CQND ITIONA Oe MICH MIT98 NMP I Icgn I;Y-u POLICY FXP A00% BURR Y NUIIABER POUCYEFF M3RTYPE OF INSURANCE POLIC _0M&Rt0=_ LTR -An. 14 03/23115 F_ACHOCCURREII,;E 2,000,12100' A OEMERAL LLA61LITY ()SSBjkILd326 03/231 vFi4 DUN 9 To RrNTE( rs too am af r ral �$ l 10q0_111_100 X COMMERCIAL GENERAL LIAL41LITY MED..EXP(Any or I Demo") �S ,0111100 MADE 7X OCCUR CLAIMf, 1 2,000,000 PERSONAL&ADVINJURY GENERAL AGGM BATE $ PRODUCTS-COf 1510P A-0.1 S 4,000,000 GEN't.AGGREGATE LIMIT APPLIES PER: $ 7 POLICY EX I P.1210•T LOC CDMSINED SINGj.H LIMIT AUTOMOSILH UABILrrY M1791 8 03123114 03123/115 (Es accidario 1,000,000 ANY AUTO 22D.!jY INIUI�ILI I Pr parson) BODILY INJURY(p"acd,;"o ALL OWNED AUTOS X scHrmULED AUTOS PITY DAIwj�,)E $ X HiREDAUTOS X NON-OWNED AUTOS 2,000,000 C_ X UMSRIILLA UPS X OCCUR 08SI&A.1111.4326 03123114 03123115 EACH OCCWRRE 4OG $ 2000,000 I" CLAIMS MADE A;OGREGATE DEDUCTIBLE X RETENTION S I OPO-0 ___T_11E"A T— C.Tq- 4 ..o"" 1 000.000 .M.Ra LAS OCCUR C =1X1 --'LL--=CLAIM1 KER _nON o jECCM5940 D wOR 3 cOmPENeA 600,000 AND EMPLOYERS' UARILITY YIN E.L.EACH ACCID!NT ANY PROPRIETORIPARrHOUEXECUTI'dE MIA 500,000 OFPCERIMGMSER EXCLUDED7 E.L,Oj9EA_-E-EAf!MPLOYN9 5 AM.M—Y[A WHI E.L,DISEASE-PO-ICY LIIAI*:' 6 600,000 14 ddorilm under D$6RIPTION OF OPERATtOP49b-16- DESCRIPTION OF OPERATIONS I LOCA11014113 I VEHICLES(AttPoh ACORD 191,Additlonal ROMP"St1OdU19,it mom apses Is,requ'rod) Operations typical to cornimarcial and residential electrical con(rcictor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBEDIP01 HIES l3r,:CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL 'as DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS North Andover,MA 01 W AUTMURIZCO REPRESENTATIVE Attention: Jong'Ilan?A. Samel ACOI ACURD (2009109) The�CQRD name and logo are registered mark;of ACOR13 i f] {S1QN 05s P FES ONAL LICENSURE $ C] 1 h 8t" t 'II.!" ..Yi Iwuvnark-+V, ,^'fY.'n S " " uh■�9 UW � r ' r �� iy "'iL5 �� h �d• �� .y�, ',nt ti �ttR Y.� YpEP75ENUMBL-11 »YEA R TI N 7AT t4 3Ci94^L : 1V1s1oM 0E'1 FVOFE Iti NAL LICirNSUf�� "�+ �tlC E JSE NUMBEN EX>�IfZAT! h1 ATF $CR'I'AC Ni 1P71L'EI r IF • i • v �u r•