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EP-79515
C)e TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 79515 PHONE: 508.910-1820 FAX: 508-910-1838 Name: Pro e caner: ✓ Date f 13 , p_ Job Location: (17 J ( C. // i tf ;: ° '-7 5 `, i Map: Lot: (; Description General Ledger#'s Ref. # Amount Building & Building Misc. 01000- r1/Uty Electrical 010 4 ?' f °°" t.� , I Plumbing & Gas 010 t 0=441 ' Trench Safety 01001 44129 v <5 ,"..r, Other Department Revenue 01000-42,' ! 1131t4 " Y ' , �.-. r ii (.>4�' t// White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy- lv Building Department ReCee(1$� �:}F��' ,.J � THIS IS NOT A PERMIT/LICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS /7if /1 — • Print For., < [ ornrxaaoea[th or�t 9a6sachtdet —� ...--0 iicial Use Only r• t s-t� Permit No. "�` >Ucpartraatnt a sra ervice4 1 r lgt V Occupancy and F: Checked ' ' BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07] (leave.lank) APPLICATION FOR PERMIT TO PERFORM ELEC TRI SAL WORK All work to be performed in accordance with the;\lassachusens Electrical Code(M•7).a")t CM .00 (PLEASE PRINT IN INK OR TYI'1_ ILL INFORMATION) Date: 1/ c ' /,J City or Town of: 7�J Vde//7/ To line Ittsl eclo of Wires: By this application the undersigned gives otice o 's or her intention to perform the e ectrical work described below. Location(Street ` tuber) /)a _>�S(4i.,(�1) /, - _ \ Owner or Tenant i'J/)/ / , / Telephone No 8l7/J �(J Owner's Address 5� //f 37d Z.Z-SL v / .61 6 Is this permit in conjunction with a building permit? 'ices No 101 (Check Appropriate Box) Purpose of Building RESIDENTIAL Utility Authorization No. Existing Service Amps I Volts Overhead _ Undgrd No.of Meters New Service Amps I Volts Overhead Pi [-''ndgrd D No.of:'deters Number of Feeders and Ampacit Location and Nature of Proposed Electrical Work: BURGLAR ALARM Conic ction of the follow luC table may be waived bv the inspector of Wires. No.of Recessed Luminaires r o.of Ceil:Susp.(Paddle)Fans IINo.of Total 1 'Transformers KVA No.of Luminaire Outlets (No.of Hot Tubs Generators KVA Above In- :No.of Emergency Lighting No.of Luminaires Swimming Pool C'rnd. ❑ arnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS 1No.of Zones �. 1No.of Detection and No.of Switches No.of Gas Burners i Initiating.Devices "Total No.of Ranges INo.of Air Cond. Tons iNo.of Alerting Devices heat Pump Number Tons I IiW iNo.of Self-Contained II Totals: I ,Detection/Alerting Devi No.of Waste Disposers ces No.of Dishwashers Space/Area Beating KW Local El (..,J❑ Other h Connection No.of Dryers 'Heating Appliances KW [Security Systems 12 No.of Devices or Equivalent No.of Water I' , No.of No.of Data Wiring: Beaters Signs Ballasts No.of Devices or Equivalent No.Hydromassaae Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required hr the Inspector of(Fires. Estimated Value of Electrical Work: $400. (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 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. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and peiaalties of perjury,that the information on dais application is trite and complete. FIRM NAME: BURNUP AND SIMS LIC.NO.:A18365 Licensee: CHRISTOPHER J.TREMBLAY Signature(...�.---- '7 / 7 ' �_;_, LIC.NO.: (I,fapplicable, enter"exempt"in the license number lute-) Bus.Tel.No.786 270-4095 Address: 57 HARRIS STREET NORTH ADAMS,MA 01247 Alt.Tel.No.:561 254-8610 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. SS-002140 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not hare 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/Agent Signature Telephone No. PERMIT FEE: S — 1 C'.\ The Commonwealth of Massachusetts \� U Department of IndustrialAccidents www.mass.4oi/clia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO 13E FILED WITH TI16.PERNIFIii NG AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):BURNUP AND SIMS Address: 10400 NW 37TH TERRACE City/State/Zip:DORAL, FL 33178 Phone#:786 270-4095 Are you an employer?Check Ole appropriate hot: • Type of project(required): I o✓ tam a employer with 10 eyoployces(lull and/or port-time)° 7. New construction 2 t am a sole proprietor or partnership and have no employees tyorking for me in 8.'❑ Remodeling any capacity(No trorkers'comp insurance required I 9. ❑Demolition 3 I 1 am a homeowner doing all cork myself iNo workers'comp insurance required(' 4❑I am a homeowner and trill he hirim_contractors to conduct all[cork un In propem I0 Building addition I trill ensure that all contractors either have corkers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees I2.❑Plumbing repairs or additions 5.0 I ant a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 14.❑✓ Other BURGLAR ALARM 6_0 vVc are a corporation and its officers have exercised their right of exemption per MMGL.c. — 152. I(-t).and we have no employees (No workers'comp insurance required I "Any applicant that checks box;I must also fill out the section below showing their workers'compensation policy information. t Iiomeowners echo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a peer aflidar it indicating such Contractors that check this box must attached an additional sheet show inc the name of the sub-contractors and state whether or not those entities have employees, lithe sub-contractors have employees.they must provide their workers'comp policy number. I an an employer that is providing workers'compensation insurance f'ur my employees. Be/ow is the policy and job site information. Insurance Company Name:ACE AMERICAN INSURANCE CO Policy 14 or Self-ins.Lie.j/:WLR C4$5895$3 Expiration Date:9-16-2016 Job Site Address:ALL LOCATIONS CityiStatel7ip: __ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under vIGL c. 152.§25A is a criminal violation punishable by a tine up to S1.500.00 and/or one-year imprisonment.as well as civil penalties in the form of'a STOP WORK ORDER and a tine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certifi'under the pa y%nd penalties of perjury that the information provided above is true and correct. Signature: ' f J� Date: to-2 -2n15 _. Phone Th 786 270-4095 1 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 S. Plumbing inspector 6.Other Contact Person: Phone#: Ali� DATE(MM1DOfYYY1) ® CERTIFICATE OF LIABILITY INSURANCE 09/17/2015 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(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 CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER INC.N.Eat): I FAX NO): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: Ann:Atlanla.CertRequest@marsh.com I Fax 212-948-4321 INSURER(S)AFFORDING COVERAGE NAIC a 605106-Cas-15-16 MAS• INSURER A,ACE American Insurance Company 22667 INSURED INSURER B:Indemnity Ins Co Of North America 43575 MasTec North America,Inc. 10400 NW 37th Ter INSURER C:Commerce And Industry Ins Co 19410 Dora!,FL 33178 INSURER D:ACE Fue Underwriters Co 20702 INSURER E:Agri General Insurance Company 42757 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003435019-04 REVISION NUMBER:8 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. INSRCY EXP L TYPE OF INSURANCE INSD WVD POUCY NUMBER (MM POUCY W! IMMO DOZY ) LIMITS A X COMMERCIAL GENERAL LWBILRY XSLG27397359 09/15/2015 09/15/2016 EACHOCCURRENCE s 1,750,000 GTO I CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $ 250,000 X SIR$250,000 MED EXP(Airy one person) S SELF INSURED PERSONALS ADV INJURY S 1,750,000 GENII AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE S 20,000,000 .2L1 POLICY JEECT [II LOC PRODUCTS-COMP/OPAGG S 6,003,000 OTHER S A AUTOMOBILE LABILITY ISAH08858950 09/15/2015 09/15/2016 COaacddemMBINEDSINGLELIMIT $ 5,000,000 (El X ANY AUTO BODILY INJURY(Per person) S X ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS x AUTOSED PROPERTY DAMAGE(Per ecddent) S S C X UMBRELLA UAB X OCCUR BE 020688007 09/152015 09/15/2016 EACH OCCURRENCE S 5,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE S 5,000,000 DED RETENTION S S B WORKERS COMPENSATION WLR C48589571(AOS) 09/152015 09/15/2016 x AND EMPLOYERS'LIABILITY YIN STATUTE iv A ANY PROPRIETOR/PARTNER/EXECUTIVE WLR C48589583(AZ,CA,MA) 09/152015 09/15/2016 EL EACH ACCIDENT S 2,000,000 A OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) WCU C48589613(FLGA,NC,TX) 09/15/2015 09/15/2016 EL DISEASE-EA EMPLOYEES 2,000,000 lips,describe under SIR$1.5M for FL,NC,TX/$1 M for GA EL DISEASE-POUCY UMIT S 2,000,000 DESCRIPTION OF OPERATIONS below _ D Workers Compensation SCF C48589601(W) 09/152015 09/15/2016 2,000,000 E Workers Compensation WLR C48589595(TN) 09/152916 09/152016 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required) Bumup and Sims is included as Additional Insured with respect to the General and Auto UabilIy policies where required by written contract or agreement.Waiver of Subrogation is applicable where required by written contract or agreement 1 CERTIFICATE HOLDER CANCELLATION Bumup and Suns SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 800 Douglas Rd.Penthouse THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Coral Gables,FL 33134 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA inc. Manashi Mukherjee 'NoLuoess..: aAatt ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD . , 3^* • _r § § lf \ (A § \ r � . ° 8 4 ( f o / \ . . 0 { . e' ) ` §\ u \ \ \ ; ƒQ sk . \ 2 : -, g m \ \ \ / R m» , \ \ E \ .p..x \ a ,,. w 3 7 � x=y2 q2 < . , 0 0 we t : \\