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HomeMy WebLinkAboutSecurity System (ooMmonw#JA oI M. eu MJ official Use Only Apar nt 0/—%s �srvaced Permit No. BOARD OF FIRE PREVENTION REGULATIONS icy and Fee Checked F-e%-1/071 (leave,blank APPLICATION i ELECTRICAL All work to be performed in accordance with the Massachusetts Elect€kd C (MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z�L7 11 City or Town of ' )/JAY)�/)'C To die 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)� ��/� Owner or Tenant sj�sf/�' l"j� �/�?,r�,t� Telephone No.�/� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Bog) Purpose of Building - f j� Utility Authorization No. .Existing Service Amps I Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps I Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .SGTIM,W-7 -5%>%�29112 Completion o the ollowin table!a he waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil,-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [3 In- 1:1o.o Emergency Lighting rud. rad. Rgyerj Units No.of Receptacle Outlets No.of Oil Burners FME ALARMS No.of Zones No.of Switches No.of Gas Burners Na o Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pump Number Tonso.o Sel - ontaine Totals: """......"" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Loea!❑ Municipal Q Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or E uivalent No.of Water KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP a ecommumcationsWiring: No.of Devices or Equivalent OTHER: Q w Attach additional detail if ales7red,or as required by the Inspector of Wires. Estimated Value of Elec 'cal Work: l/ �� (When required by municipal policy.) Work to Start: L Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under theains and penalties of perjury,that the information on this appficahon is true and canrlete, FIRM NAME:/ S ' LIC.NO.: .3UC— Licensee: Signain G LIc.No.z—e�W? �v�� (Ifapplicable,enter"exempt"in the license number line.) y Bus.Tel.No.���U=��?� `Per M.G.L,c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. ,:�3� 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 ❑owner ❑owner's ent. Owner/Agent Signature Telephone No. �� 17'FEE.$/S The CommonmeNth of M Depgrhnsnt of 1 nobstriaf Anddents Office of I nw0gations 1 CangreesSbaK Suite 1W MA 42114-2017 www nsasgowda Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant I nformation Please Print Lectibly Name(Business/Organization/Individual):,6a/--Z&/- Address:zLe) /�i'1-1L" O /�c' ( - Q0 City/State/Zip: ' �1 Phone#: l Areyou an employer?Check theappropriatebma Typed project(required}: 1. I am a employer with C2� 4• ❑ I am a general contractor and I employees{full and/or part-time).* have hired the sub-contractors G. [1 New construction 2.[)1 am a sole proprietor or partner- listed on the attached sheet. -1. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. [:]Building addition [No workers' comp.insurance comp.insurance. required.] 5. ® We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[3 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+EJO'th employees. [No workers' #J th comp.insurance required.] *Any applicant that checks box#1 trust 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-contr tors and std 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 my employee. Below is the policy ar d job site Informant:m Insurance Company Name: /% /r,rj'� _ Policy#or Self-ins.Lie.#: 0:3 Expiration Date;-3//���5 Job Site Address:�0e and/y- City/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 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 hwrebycertify des Of per%wy that 9reinfarmatronpraut Waboieisbwand corred &Snature: D at e: r Plot e#: i>i / /, Official utas only. Do not atWts in fiVsa m,to be aanp/eftdbydiyar town datiaiaat. City or Town: Permit/L€oense# Isa3t,tingAuthority(drde": 1.Board of Health 2.Build€ng Department &City/Town Clerk 4.Electrical I nspedor 5.Plumbing i nipedor &Other ContP #: MO UWE ALT • tit;ns:R a.. i et g sa "ISSUES KT#F f0LL INI 4 v.B I CONTRACT ALAR CO 'd2tNAttl ULO 301 N S b 1 4 MAM A' EKS 10 :r. .7� d �M IX-23 4+841 0 " n�I � ® � • � � V a 4+` t� �+ -�.�t -�y{ ryp�� `i• y •.1S'R��{r.w n yry�v' •'r:i ISSUES:�Pif FOLLOWIN '1r E1 5E IgFS RED jl�'K TECHNI£17 D L PALL I ARtfld 301 ME406 ST �:y,::' �`��*'ti�F`t,� ;, •.:. v or Nay,. �, ,a•4`�`�.��I~�.��a,Y,x`n�,y�,q�^:.r,••mar•(yk�v;� '� ���1�,Z,�'"'�(y�vy�t, s���` .. ensu- SSCO-000332 RONALD L PAOLiAROLO 100 Trade Center Ste 440 Woburn MA 01801 06111/20155 FIRST-3 OP ID:SM A�oRo CERTIFICATE OF LIABILITY INSURANCE 1 DATE03/127/201427/2014 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 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 endorsement(s). PRODUCER CONTACT Martini Insurance Agency,Inc. PHONE FAX 6 Common Street a/c o Ext): A/c No): PO Box 565 E-MAIL Woburn,MA 01801-0665 ADDRESS: Martini Insurance Agency Inc INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Hartford Insurance Company - INSURED First Alarm LLC INSURER B;Travelers Ronald Pagliarulo 100 Trade Center Suite G700 INSURER C: Woburn,MA 01801 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE D UBR POLICY NUMBER POLICY EFF M°�DI EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY OBUENOJ9837 10/11/2013 10/11/2014 DAMAGE TO RENTED- PREMISES E TEDPREMISES Ea occurrence $ 300,00 CLAIMS-MADE FKOCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO- LOC Prof Liab $ 1,000,00 '.. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 a accident _ BANY AUTO BA-7D919644 10/31/2013 10/31/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ent AUTOS AUTOS ( )BODILY INJURY Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATIONX WC STATU- TH- AND EMPLOYERS'LIABILITY O Y LIMITS E A ANY PROPRIETORIPARTNER/EXECUTIVE Y/N 08WECCP6487 03/13/2014 03/13/2015 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,00 ('FSCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Operations of the named insured for installation and servicing of Alarm systems. CERTIFICATE HOLDER CANCELLATION FIRSTAL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN First Alarm LLC ACCORDANCE WITH THE POLICY PROVISIONS. 100 Trade Center Suite G700 Woburn,MA 01801 AUTHORIZED REPRESENTATIVE U C_ Ca U ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD