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Home My WebLink AboutWire Permit - Permits #12912 - 384 OSGOOD STREET 11/13/2014 MANOR Ell NT Date _ \\ .... gi MEW TOWN OF NORTH ANDOVER SO PERMIT FOR WIRING ff AN 010 4iu ?200\ ak \\ `\ This certifies that y \ ..,. \ �� .. ....... ......... .... � \\ l \ IS V gl has permission to perform \ T. ..... .... M wiring in the building of \� \l\ at,,... , Forth Andover, Mass. Owl Fee. ...,:..:. Lic. IoTo. _.�K... - .. ...................................................All ELECTRICAL INSPECTOR...................... \\ >gg\gw Check # gq �`\ `01 o �. �. �. �. � `. 4 1 �, �. �. �. �. �. � 1. S �� Commonwealth of Massachusetts Official 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: November 10, 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) 384 Osgood Street Map: Lot: Owner or Tenant -Town of North Andover Highway Department Telephone No.978-685-0950 Owner's Address same Is this permit in conjunction with a building permit? Yes El No Z (Check Appropriate Box) Purpose of Building Highway Department Utility Authorization No. Existing Service Amps —Volts OverheadF] Undgrd ❑ No.of Meters New Service Amps Volts OverheadF_1 Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Garage Completion of the following table may be waived by the Inspector 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 Above Ei In- F1 f Emergency Lighting �11 Na.of Lighting Fixtures Swimming Pool grnd., grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones Nt No.of Detection and .of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump [Nqqy�r 1.19Rs JKW No.of Self-Contained No.of Waste Disposers Totals: ....................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local M Municipal M 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 Signs Ballasts No.of Devices or Equivalent No Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Replace existing wiring and devices in garage. 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: 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� (Specify:) I certify,under the pains andpenallies ofperjury,that the information on Ois cation is true and complete. FIRM NAME: Andover Electric Services, Inc LIC.NO.: 14302 Licensee: Robert J. Branca Signatqre" LIC.NO.: *Per M.G.L.c. 147,s. 57-61,security work requires DepaffiTient ofXublic Safety"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, lam the(check one)E]owner R owner's agent. Permit Fee: ❑ Owner/Agent Signature Phone: C � CERTIFICATE OF LIABILITY INSURANCE DATE ( YYV, oa/28/201/2o1a 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 RgPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(ies) 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 CONTACT Samel Insurance Agency,Inc. JONATHAN M SAMEL CIC LIA PHONE IFAX 978.474-0890 .La No Ext:...978.474-0810 IC No: �_... SAMEL INSURANCE AGENCY,INC. EMAIL info@camel-ins.cam 15 CENTRAL STREET ADDRESS: PRODUCER ANDOVER MA 01810 CUSTOM RI : 1254 INSURER($)AFFORDING COVERAGE NAIC# INSURED —INSURERA :Sentinel insurance Co,LTD 11000 ANDOVER ELECTRIC SERVICES INC PO BOX 629 INSURER :Citation Insurance Company 40274 ANDOVER MA 01810 INSURER C :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, INSR TYPE OF INSURANCE ADD'L SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MMIDDIYYYY MMIDD LIMITS A GENERAL LIABILITY 08SBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE_ $ _ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Me occurence _ $ 1,000,000 CLAIMS-MADE I7 OCCUR MED.EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY X PRO LOC $ B AUTOMOBILE LIABILITY KW7918 03/23/14 03/23/15 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,04 ea, ALL OWNED AUTOS BODILY INJURY(Per person) $ X SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE r X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ C X :UMSRELL:A�L1:AB X OCCUR 08SBAIL4326 03/23/14 03/23/15 EACH OCCURRENCE 2,000,000 CLAIMS-MADE AGGREGATE 2,000,000 _ DEDUCTIBLE 1 X RETENTION $ 10,000 $ I ® WORKERS COMPENSATION $04/20/14 _.04128/15 „, ..4TVC9 LN,giTg_.. OTH AND EMPLOYERS'....UASILITY _ YIN OBWECCM5940_ _. _ _... ...... V ..-`..... ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH.ACCIDENT 500,0 0 OFFICERIMEMBER EXCLUOEO? I N I NIA _. (Mandatory In NH)and - E.L.DISEASE-EA EMPLOYEE 500 0A0 Dyes,describe under r x 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 Street A THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: _ Cp Jonathan Samel ACORD 25(2009/09) C�71988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents w Office of Investigations a d 1 Congress Street, Suite 100 Boston,MA 02114-2417 w www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le gib Inc. Name (Business/Organization/Individual): Andover Electric Services, _ Address: 19 Dales Street City/State/Zip:Andover, MA 01810 Phone 4:978-475-4995 Are you an employer? Check the appropriate box: Type of project(required): 1.9 1 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 g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑ Building addition [No workers' comp. 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 11.❑ 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 employees. [No workers' 13.❑ Other comp. 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and jab site information. Insurance Company Name:The Hartford Policy#or Self-ins. Lic. #:08 WEC CM5940 Expiration Date:4/28/15 Job Site Address: 384 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 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 p°gans and penalties of perjury that the information provided above is true and correct. . M � November 10, 2014 Si nature: ,�""" Date: Phone#: 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 Then Debmh AWW AN Perfomuom r r • �-• r r r t e � r� Fold,Then Detach Moog AM Pertor9 iom r r YM x,. fr' �} hi 0 - +ad�w ' 'SSG ' ,��` A� >r N�,F � v`79nf✓/.d f .rf�` � 7,1�A{y t"t i e� t ",'•, 4 /� p��Iy sky STATE.OF NER�y�HAM SHIRE BOARD DAME; .RO m �k EXPIRES... 1