HomeMy WebLinkAboutWiring Permit - Building Permit - 266 BLUE RIDGE ROAD 7/7/2015 i
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Date
NORTH AND0NJ
�pRTh 4 TOWN OF N
PERMIT" FOR WIRING
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B6 C14Ug� 3
. ........ .... ........................................................
This certi ....................................
fies that
haspermission to perform.....
........................
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wiring in the building of . North And over,Mass.
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L1C.NO:'................. ELECCTRICAL INSPECTOR
Fee
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Check# ---- ��
___ otnmonwea�ti.o�Y��addac�iudelTd i icial-Usee Onh
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No. 104-1 G�
pat Em of d gh-e Se,viced
BOARD OF FIRE PREVENTION REGULATIONSncy and Fee Checked
71 (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
(PLEASE PRINTW INK OR TPPE.4LL.1NFORA2,4TIOA) -Date:
City or Town of: To the Inspector of
13y this application the undersigned gives notice of his or her intention to perform the electrical work described below,
Location(Street c&Number) (Z(�jj ► r ��
Owner or Tenant �� : � ��'� Telephone No ��{ �r
Owner's Address
Is this permit in conjunction with.a building permit? Yes ❑ Na nn (�
s V�I (Check Appropriate Box) �\
Purpose of Building Utility Authorization No,
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No, of Meters
Ney� Service
Amps / Volts Overhead❑ Undgrd ❑ No, of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the follow, table crap be reaived by the L7spector of Wires. `\
No.of Recessed Luminaires No.of Ce'il.-Susp.(Paddle)Tans No, of Total cam
Transformers VA
No.of Lumfnaire Outlets No.of Hat Tubs Generators KVA
No.of Luminaires SwimmingPool Above ❑ In- ❑ o, o �'mergency rgnung
�rnd. arnd, Bane �Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones
No.of Switches No, of Gas Burners No, o�f Detection and
hl iitiatinQ Devices
No..of Ranges No, of Air Cond. Tons No. of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons ICVI' No. of Sett=Contained
Totals: ..........•....._......•.................................•....._.._...........
Detection/Alerting Devices
No. of Dishwashers Space/Area Heating I(M' LocaI Municipal 0fhPr
❑ Connection
No,of Dryers Pleating Appliances g�, Security Systems:*
No.of Water No, of No.of Devices or E uivalent \ _
Heaters I Ballasts
of Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Estimated Value ofElectrical Worlr, AA) / ilttach additional detail if as desired,or required by the h7spector of ff"ires.
gU co (When required by municipal policy,)
Work to Start:, ks S KR 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 Iicensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned dertines 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 thepains andpenalties ofperjury,that the information on this application is.tPiue and.complete. 1
TIRMNAPMK: ADT LLC .DBA ADT Security
—1 •� LIC.NO.: C-172
Licensee: Thomas J. Lee Sign�ure _��,..�' LIC•NO.. C-172
(If applicable,enter "exetnl�t" i7 the licepse number ,('_. / i_
Address: 1 U(� QC.- ; \Clt� U Bus. Tel.No, � �J���
`Per M.G.L.G. 14.17,s,57-61,securityworx re uires!� Alt.Tel.No..
q r cin2nt of-lublic Safety"S"License: Lic,No. �S 00 J'7'7�
-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 El owner's a ent,
Owner/Agent
Signature . Telephone No, PRIIIIT FEE:
f_ .. - ,�_�=JT:-c5:4 s�.ri�__.:n___ra__.r_-___•ah_.=3e—�_.-�":iL:-_L._v� =�=x_�s_.:.—s=_._____
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r: •�a.- ,. :;�• r•;,`�Chu:;.• . "•{. �. i�
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''ir• ::3.i.' Y 't L/�f2,•V�9O"��•„1 1•.I• ''cam-'--•�, -:t+ •
_ i.if-(I-,��=.�' i r 5.. �:.o t c,V: 's :"�'�• s ,Y.=�. •. ... _. is
.. �:_ ._.._... ___._ ,_•• fig• - - ^--...:;-•-- -r•�—'_�..:-�.>�;>�-`-_'_-r'_;;�-•.• t
_ common-Ole alth of Massachusetts "
Department of Pubiic safety ;
ticcurin•$?'strtns-5-Licener -: - '
License:ss-009779 :�'
Thomas J Lee 'r ` ¢ •_
410 universityAve �
Westwood la(IA-5 02090RIC ,v^ . M1
1�
Expiration:
Commissioner 0 /96/2016
FO,
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-A
Ofj tee of Investigations
600 Yflashintoyon SIMI
Boton,,411A 02111
MPIVIYnasy.govAlia
worken, ConipengArion, ffnsUT, ,qUC(,-Affidavit'
ie so richa offib
Frint L__RML�
'
Nallf 0(Business/0.rganization/fnd N
Address 12�,
........... .... ...
Pholio#:
City/Mate/Zip:
A ll.Ara yet,a employer?Check tile appropriate propriato box-: Type of project(required):
,Oyer with
1.[A-1 am a employer —\��0 4. ❑ 1 am a general contractor and I 6. 0 New construction-
employees(full and/or part iimo).* have hired the sub-contractors 7. El Remodeling
2.Elf am a solo proprietor or partner- listed on the attached sheet. E]Demolition
ship and have no employees These sub-contractors have
workers, comp.insurance, 9. r]Building addition
working for me in any capacity.
[No workers' comp,insurance 5. E] We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
required.] right of exemption per MOL 11,[]plumbing repairs or additions
3,El I am a homeowner doing all work c.152,§1(4},and we have no 12.rl Roof repairg
myself,[No workers'comp.
employees.[No workers' 3 Other_k---()
insurance required.]t
comp.insurance.required.] sot%SA
'Any applicant that checks box#1 must also fill out the section below sho.wing their workers'compensation policy information, i
Ti-forneowners who submit this affidavit indicating they are doing all work-and then hire outside contractors must submit anew afffdavit indicating such,f Iii
. 0 lation,
tCoj)Lractors that check This box must attached an additional shoot showhig the name Of the sub-coutcaotol8 and their workers'comp.policy hi
.
.1 all,(M employer that,lyprovldh�,-ivorffe,&coMPO!Isadoll inspi-ancefor rq erf�Tjoygey Bel ojv.js t1te.ly My andjob sit
information.
fasurance Company Name:
Policy#or Self-ins,Lio.#:
W
c�
t4
fob Site Address. City/State/Zip'--LL4 L__,
(811oviing the policy.-ijumber and expiration date).
Attach a copy Of the Workers compensaf To,,poijuy declaration page
Failure to secure coverage as required tinder Section 25A of MUL c. 152 can lead to the,imposition of criminal penalties of a
-me
file 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 f
of up to$250.00 a day,against the,violator. Be advised that a copy of this statement may be fonvarded to the Office Of
Investigations of the DfA for insurance coverage verV:-aflon•
ffitt yr po tre and co; 9
a 1le111oriairided above is .
Date.
cijy or town oJilcklal
Citr or Town: Formit/f Jeense
Issuing Authority(cirelo one): nt 3.Citygo-rqrt Clerk 4.electrical Inspector 5,Plumbing Inspector
L Board of Health 2.Building PepartmO
6.Offior
Corifiaet.Person. Phone ff.
,4co CERTIFICATE OF LIABILITY INSURANCE D 10/08/2014 /YYYY)
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(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:
1560 Sawgrass Corporate Pkwy,Suite 300 fPAHONN Ext): A FAX
No
Sunrise,FL 33323 E-MAIL
Attn:FtLauderdale.Certs@marsh.com ADDRESS: —
INSURER S AFFORDING COVERAGE NAIC#
048953-ADT-GAW-14-15 _ INSURER A:Zurich American Insurance Company 16535
INSURED IN B:American Zurich Insurance Company 40142
ADT LLC
18 Clinton Drive INSURER C:
Hollis,NH 03049 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-003303542-01 REVISION NUMBER:2
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 ADDL SUER POLICY EFF POLICY EXP
LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
A GENERAL LIABILITY GILD 5095899 02 10/01/2014 10/01/2015 EACH OCCURRENCE _ $ 2,000,000
X PRE SESO(Ea occcurrence S _ _
_ COMMERCIAL GENERAL LIABILITY 1,000,000
CLAIMS-MADE �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
X POLICY PE LOC $
B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000
Ea accide t) _ $ _
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Per accident $
AUTOS AUTOS ( ) _
HIRED AUTOS NON-OWNED PROPERTY DAMAGE
AUTOS Per accident)__,,,,_ _
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE _ S
DED RETENTION$ $
B WORKERS COMPENSATION WC 5095897 02(ADS) 10/01/2014 10/0112015 X WC sTATu- OTH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 5095898 02 (MA,WI) 10/01/2014 10/01/2015 2,000,000
OFFICERIMEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT S
(Mandatory in NH) E.L.DISEAS_E__-"EMPLOYE 2,000,000
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Town of North Andover is included as additional insured(except workers'compensation)where required by written contract.
CERTIFICATE HOLDER CANCELLATION
Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN:Electrical Inspector THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
124 Main St, ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover,MA 01845
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee _ Lim cnts�. � L.x lc_nu a ct
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD