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HomeMy WebLinkAboutWiring permit - Building Permit - 365 BLUE RIDGE ROAD 9/3/2014 Date,. .�.. � °6 NORTF�4 ��:' _� .'•�°o� TOWN OF !NORTH ANDOVER o m PERMIT FOR WIRING 88�CHU t This certifies that has permission to perform a ........... ............. wiring in the building of... at c,. ry..NojutkAndover,Mass Feet .. .. �:........Lic. No. ..� EL cnicAL INSPECTORtr� i CheckIF E I f t fe *afn wan Iw , , I OR&L APPLIGAVON FOR Pr--:,P ,V&r To Pr-RFO Rc,N1 ELECTRI CAL WORK ALI work fo UO&E(wq w k.M gums CRAM NM A W)-/V) MIX to,And Sk ;9311946 of him, OZ AD).futmaq to pe ozan tho ckddoal y"Ork desclihed bi4oly, Ail pumpe XY-t a ma's4QW40 AsT ---- pn� 1 Myllf"I its divows MAWN Ali' f its 0 vadk 6 a 61 xo�Of meie4Lq Arks 0XV08-amal MyMPTI&Y 9 lc-..rpedbv Mlok'spe f fyins.127i�46#01 of*' folfant" p -P.(ead fu6y'Va4s YV .0 El A I Mg A10. 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'`Ik 1!•� I' f Gomrnonvraalth of Massachusetts is Department of Public Safety Securih-Sv-tem3-5-Licener — License: SS-001779 e =X= 9.tt°r�a5.➢"T..n. =�`�~t,�.��. /'�(�r :�'Z'=-'''''+;- t 41.0University-70e. Vies twoodWt 02o9G s3 - S 6' Expiration: ~ commissioner 05/16/2016 ' i f ' E - � t r i f f • � f I i DATE(MM/DD/YYYY) AI`Co� � CERTIFICATE OF LIABILITY INSURANCE F 09/25/2013 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 'T certificate holder in lieu of such endorsement(s). rz PRODUCER CONTACT 'D NAME: Aon Risk Services Northeast, Inc. PHONE FAX 0) Morristown N3 Office (A/C.No.Exq: C866) 283-7122 A/C.No.: <800) 363-0105 '06 44 Whippany Road, suite 220 E-MAIL 0 Morristown N7 07960 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Zurich American Ins CO 16535 ADT LLC INSURERB: American Zurich Ins c0 40142 ADT Security Services 1501 Yamato Rd INSURER C: Boca Raton FL 33431-4408 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570051395419 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. Limits shown are as requested INSR TYPE OF INSURANCE ADD S BR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY GLO EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1,OOO,OOO PREMISES Ea occurrence CLAIMS-MADE ❑X OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 rn GENERAL AGGREGATE $4,000,000 rn PRODUCTS-COMP/OP AGO $4,000,000 M GEN'L AGGREGATE LIMIT APPLIES PER: � X POLICY PRO JECT LOC o AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT u7 Ea accident ANY AUTO BODILY INJURY(Per person) O ALL OWNED SCHEDULED BODILY INJURY(Per accident) y AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE O AUTOS (Peraccident) w t" v UMBRELLA LIAB OCCUR EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION B WORKERS COMPENSATION AND wc509589701 10/01/2013 10/01/2014 X I WC STATU-I 1OTH- A EMPLOYERS'LIABILITY Y/N wc509589801 10/01/2013 10/01/2014 TORY LIMITS I JER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $2,000,000_ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Fri J� r �I1 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE - POLICY PROVISIONS. r� W= TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE INSPECTOR OF WIRES =: 124 MAIN ST. "� y/�y �. NORTH ANDOVER MA 01845 USA CZ c.Jr l2titcCO c.//O oy "Z. ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD '�z� � t .,,-5.u, i� �4 ,,�':o;�A g�,r'-'��J°r`1 i/�Yl�,Yy'3''•{".4�1�'igv�•9ls�'.���;�luT� 6 _ !, `F :^P�'�- } m![g1� ='• 4�i:(J`-')s'''Au4 ���11 ij�J'�:•h1�.0 s�['(..: o ��r?��)��ll",�`-s��.5+•a; :�e ��;�F�;TIy-t.L6{r�t�:��� •�(1i.� r.r!3r�,Yr�k���>� oy d§Satfk�.r�'E1r -,<`�€j' vi-OP ,P ,. 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' �f l r i '�w;?17.$'sCe"_+t'�F��7!P�d.x,�,�,N:.,��:'• �.�t�_A-�:• ,� i '. ::Y9@GA!4r,r;Pt�,&dh[p Jig Rh-0-9 • H'l _. `fP C'S, f117�+�j,YL.�i_,' {Fk�IL'i'2�(i ll�c�l'�.��CR 4•'�.� ?.3 k���:F'.�,�1�..[y' 1C'y:. , r �r[,'g+'�;�SP�'1�i1`�_�2��1{•b1Q _ I?:(L�_d�l!s£.t7°_' ° r I • ? � it r I ' - I I i Datet............................ ....... µORT►t TOWN OF NORTH ANDOVER n PERMIT FOR WIRING t j BsgCHU`3� i This certifies that s ................................................ ................................................................... has permission to perform .1...... bo-�.../ .n.. :..:... :..... .. ..................... V � wiring in the building of.. ' ' Fp f at ...� ��„.. yi i.., :,North Andover,Mass. " ......... ... ......... .. Fee r.?....:.. Lie,No �..E. �4 .Zj_ ....... ..'...., F ...:. ..ELECTRICAL INSPECTOR ep Check# �� . Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. � -- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives not ic o s or her' to ion to perform the electrical work described below. Location(Street&Number) r r Owner or Tenant 0 e 'P f A Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building _!� � 0 Utility Authorization No. Existing Service l» Amps OCl/ IWO Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,�v/r l�vC �� t f/nl d& bfisE &W— Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires f,I' No.of Cell.-Susp.(Paddle)Fans No,of Total Transformers KVA No.of Luminaire Outlets No, of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ ❑ o.o mergency Lighting rnd. grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones No.of Switches No.of Gas Burners No. of Detection and evices / No.of Ranges No.of Air Cond. Tons No.of Alerting gng DDevices ®a1` HeatPump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: """"""""""""""""'"""""'s""""""""""""" Detection/Alerting Devices '71- No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW SecN t o.o Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent- OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 20M (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. CBECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: 17,41Y Signature __ LTC.NO.:�G i'zC (If applicable,enter "e mpt"in t lice a nttm er lin . Bus.Tel.No.: Address: ; G v� �% `� Alt.Tel.No.:_9 7k 2k 9 y *Per M.G.L c. 147,s.57-61,Vourity 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/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an electrical permit shall be issued to.the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP ON: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: f �, p Date: /U — FINAL INSPECTION: Pass(] Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflntlustrialAccitlents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/fndividual): Address: `t C) City/State/Zip: n Phone# 7 �� 7 E�-3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.f?k am a sole proprietor or partner- listed on the attached sheet.# �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g 0 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] of 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]r employees. [No workers' q ] 13.❑Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7'Homeowners who submit this affidavit indicating they aie 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 their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date:: / Job Site Address; 6 '� l pity/state/zip: ./`/=, 0AC&))aA_ Attach a copy of the workers'compensation-policy 14claration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 c r nder the Wnseidpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#• / CAS `7 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#: fur:... COMMONWEALTH OF MASSACHUSETTS BfJAta1�0� CLECTRICIA;NS ISSUES.THE FOLLOWING `LICENSE; t <` AS A REA JOURNEYMAN -ELECTRICIAN .. .. U 'Z CHARLC.S A FAY 20 BERESFORD STREI -2L 01843431 i 2 617 > OV '1 116 89957