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HomeMy WebLinkAboutAnnese Electrical Permit No Number C,ommonu�oa[h o` a6eaclu�d.iia Official Use Only 4,.�-�i tc'�� cc�� Penztit No. „� - 1Japarfinunf of,tu+s�itvase I't`4 BOARD OF FIRE PREVENTION REGULATIONS Occup0 cY and Fee Checked v. � leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC).527 CMR 12.00 o (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ��i l Zt J City or Town of: fp,c r-t�„ ,- To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. L. si — d Location(Street&Number) a 7<, s74 77o rl A v Owner or Tenant Pc-1v,Y(5 y,,L,Kavm' /LE41a riA�- jediv.,t- '1,)!Sr,t,,« Telephone No.Sop37e-7(0(. d' Owner's Address . 4 _S719-Tiif 4//;.is 1Is this permit in conjunction with a building permit? Yes Er No ❑ (Check Appropriate Box) Purpose of Building I- t i 7)7 6 c,tdv oh.- Utility Authorization No. U:.4/.AS/7 Existing Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters -S New Service 4d6'd Amps 2 7 7/ '14/19 Volts Overhead❑ Undgrd No.of Meters j Number of Feeders and Ampadty 2 oZ.. - A �� S 1 Location and Nature of Proposed Electrical Work: o976 STi;t -,O N At%cr-- ` ,tJ 44.9 _SG f-f u t-, e. t 1/44 Completion of the following table may be waived by the Inpector of Wires. kb No.of Recessed Luminaires No.of Cell.-Soap.(Paddle)Fans No.of Total Transformers KVA C1 No.of Luminaire Outlets No.of Hot Tubs Generators KVA n • No.of Luminaires SwimmingPool Above In- No.of Emergency Lighting _trod. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Barnes No.of Detection and • ' Initiating Devices 1 U No.of Ranges No.of Air Cond. Tans No.of Alerting Devices No.of Waste Disposers Totals: Pump plumber_ T ons,.__KW 'No.of Self-Contained - Totals: Detection/Alertingpevlces No.of Dishwashers Space/Area Heating KW Local 0 Munnenkictipsrlon 0 Other, Co No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsNofDevices r Equivalent No.of Devices or Equivalent }OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: u f- ��, 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 licensee 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. ONE: INSURANCE [BOND ❑ OTHER 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:191j,t/ S E f= Ecraj Got.- -SELL✓! E.5 LIC.NO.: Licensee: T e p rt 13 N 1, is c L Signature jj�'�'�-'Y t iim L LIC.NO.:/sz 6 C..$r (If applicable,enter"exempt"in the license number line.) lJ Bus.TeL No.:7Y/-33 7-� 216 Address: , t` 4`�3 �//- l h I% .t `i/ev/'_ U '/( 4'/)f Alt.TeL No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. 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 agent. Owner/AgentPERMIT FEE: O. Signature Telephone No. $ '`f; 'I0 RECEIVED IJUL 0 2 2021 BUILDING DEPARTMENT By: COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE WARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE REGISTERED MASTER-ELECTR:c!AN JOSEPH S ANNESE ANNESE ELECTRICAL SERVICE,INC 280 LIBBEY INDUSTRIAL PK 5 WEYMOUTH,MA 02$893102 12665 A 07/31/2022 648743 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Commonwealth of Massachusetts `® Division of Professional Licensure t � 11 f Securi s11( j�-License f. SSCO-000605 :' e i 'Expires: 09/06/2022 JOSEP S f ��EY�45►4i '`� } ; ANNESE 15LECT k O ' JsS'O1:%O Commissioner ,40.1(?,, Wf,,,;0,� HusET Ts _ A ssAc M DRIVER'S ., LICENSE . NOT FOR FEDERAL ID ,.,--2,:.,, --,.,:::. -,,,- - r.:::'e.I _Zr 7-,, ': , , ' , :, k-,l'-,e4.4.,' ,-•:.c. '' .f.'f.P4':';44--1-•'''.7,i.4`..:1:' '''.'1:::4:r11:.'''it. *Z,' '''• • '1,, :: ''. : '7'..)'f•14';',':;' ".•' si,I I SS i d NIAIBER ., . . , s, . „ ,•,,,,,4 , , ,,-,,,..: . _ 08/1012018 S94908008 `'' ''''; EXP ,. .„ .,. ;,... .,, . ',..r::,,'-.T;'Tf"; , . . 1 •11' ' :,'''''''% ' ;'" '.:..:7: . 0 ' 09/0612023 Dog. 09/06/1951 •V JA ' .. ., CLASS '''' REST 51, END , ,Il ,A,.:., ,1,.., ,-. D B NONE %tit's-4 , - .. „ -.,,.., .,.. ,t. .. .;;:: , - _ .... , ....._ ,-,& . ANNEsE 3,-,,,. ,. ,.. JOSEPH S 62 COLLIER RD ,of o , 4.0. , SCITUATE MA 02066-4639 -, ,. -...__ - - '''4 r''.--,.-4,4-,- • : :: ' ' ' ' - . — - EYES BLU SX M 1 07" fic,,T 5 - . . ,,,. ., DO 0811212018 Rev 02 09/06/51/22J2016 ,_ _ „,.. . -,...s7...„, ,,,,v evizo,.....^ow onitose4warrgeot,W, ,-,,trat„A,''ri,,' iiii...„.0.,„,4,44,op,(- ,for ri'ke.tzgia wog mg otilwamm m go!Ittoot, ,.,, ,-, -, . .r.;0 .. ,_ . .• . . .,.'„•, „ ACORO® DATE(MMIDDIYYYY) �„--- CERTIFICATE OF LIABILITY INSURANCE 6/1/2021 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 have ADDITIONAL INSURED provisions or 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 ACT NAME: Stacey Mastrangelo The Driscoll Agency PHONEAx 141 Longwater Drive, Suite 203 (A/c.No.Eat): 781-681-6656 (A/C,NoJ;781-681-6686 _ Norwell MA 02061 ADDRESS: smastrangelo@driscollagency.com _ _ INSURERIS)AFFORDING COVERAGE NAIC# INSURER A:Associated Industries of MA Mutual Ins Co 33758 INSURED 5810 INSURER B:Travelers Indemnity Co ! 25658 Annese Electrical Services, Inc. INSURER C:Travelers Prop.Cas.Co.of America 25674 280 Libbey Industrial Parkway Weymouth MA 02189 INSURER D:The Charter Oak Fire Ins Co 25615 INSURER E:Berkley Assurance Co 1 39462 INSURER F: 1 COVERAGES CERTIFICATE NUMBER:117023410 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. INSR TYPE OF INSURANCE IADDLSUBR POLICY EFF POLICY EXP LIMITS LTR' MD WVD POLICY NUMBER IMM/DD/YYYYI IMINDD!YYYY] 0 j X COMMERCIAL GENERAL LIABILITY j CO 3J704496 5/1/2021 5/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAG ro RENTED, PREMISES(Ea occurrence) $500,000 X BLKT Contractual I MED EXP(Any one person) $10,000 X XCU Hazards PERSONAL&ADV INJURY $1,000,000 'G_EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ♦$2,000,000 POLICY X JECOT- LOC ! (PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ _. B AUTOMOBILE LIABILITY BA 9M473846 5/1/2021 5/1/2022 !COMBINED SINGLE LIMIT $1,000,000 iEaeoctdentl_-___-- X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ .._-__ AUTOS ONLY- AUTOS ',.. ._ . HIRED : NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY .AUTOS ONLY .{Per accidentl I Comp&Coll Ded • $1,000 C ! X UMBRELLA LIAB X OCCUR CUP 3J992232 5/1/2021 5/1/2022 EACH OCCURRENCE $10,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$irLnnn I $ A WORKERS COMPENSATION WMZ80080066702021 5/1/2021 5/1/2022 IX l STATUTE ER H AND EMPLOYERS'LIABILITY Y/N — ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? I .. I ---- — " ---- "" (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under -- - --- --____-- DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT $1,000,000 E Pollution&Prof Liability I PCXB-5014177-0421 4/4/2021 4/4/2023 I Per Claim 2,000,000 Aggregate , 4,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Electrical Inspector ACCORDANCE WITH THE POLICY PROVISIONS. f * AUTHORIZED REPRESENTATIVE t k R II// ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD t ne t.ummunweuttn uj lrlussucnuseus Department of Industrial Accidents ; i . Office of Investigations Lafayette City Center k ,,f, 2 Avenue de Lafayette, Boston, MA 02111-1750 -t-F«e` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):ANNESE ELECTRICAL SERVICES, INC Address:280 LIBBEY INDUSTRIAL PARKWAY City/State/Zip:WEYMOUTH, MA 02189 Phone #:781-337-6462 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 65 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 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 ELECTRICAL CONTRACTING employees. [No workers' 13.0 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. 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 my employees. Below is the policy and job site information. Insurance Company Name:A.I.M. MUTUAL INSURANCE COMPANIES Policy#or Self-ins. Lic. #:WMZ-8006670-2021 A Expiration Date: 04/30/2022 Job Site Address: 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 hereby certify under the pains and penalties of perjuty that the information provided above is true and correct Signature: 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(check one): l❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5.alumbing Inspector 6.0Other Contact Person: Phone#: _ .,x^, ,t, r,,, ;..;,ti+ OFMRHAL.,000UMENY PRINTED ON CHEMICAL REACTIVE PAPERWITH MICROPRINTED BORDER-:FEE.REVERSE BIDE FOR.COMPLETE SECUR TT FEATURES -- .- .- _ `__._.__.____--.,__ _�__._.__._. - �— IN PAYMENT FOR• -__ • 8534 AN N ESE 280 UBBEY INDUSTRIAL PARKWAY ELECTRICAL SERVICES WEYMOUTH,MA 189 53-7149/2113 ----.V )UNT eti , Crrrq1U DOLLARS! CHECK TECHECKNUUMBER, TO THE ORDER OF DESCRIPTION. MBE AMOUNT "'� � - IO' J� ()(0 /v ALLA 110 0 I ,1�-- `z�,h C $ LIMO) IF 0 $50,000 TWO SIGNATURES REQUIRED d S sf �� C COASTAL HERITAGE BANK ,,,'''` Mike,.... ,:..____....•I____,.n___________la ___ .a_;_ a, . n'00853411' 1: 2 L 137L4921: 01.803I 203703e