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Home My WebLink AboutWiring Permit - Building Permit - 74 BLUEBERRY HILL LANE 6/30/2015 ( � I Date..`� ).�. ................... °F NOR7ly, �,+a ;'•�°om TOWN OF NORTH ANDOVER i PERMIT FOR WIRING 1�g8°ACHUS�t`9 I This certifies that ............ � has permission to perform .... ............ . ..... ................. wiring in the building of at ............................. ...................................North Andover,Mass. 4 ..... Lic.No. Fee ... ..... ......................................................... ELECTRICAL INSPECTOR Check# f �__0jnmonWea&11?, 0.11/lleamachtoplTd I.Se On)), Permit No. � �� I P �It2eva.116,nent Oi�fZjpe SeptlicedIC Occupancy,and Fee Checked e'v 1/07J BOARD OF FIRE PREVENTION REGULATIONS F[R Rev- 'TJ (11,11c blank) APPLICATI"ONI FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be,performed in accordance with the Massachusetts Electrical Code(IvIEC), 527 CNM 12.00 (PLEASE PRINT W NK OR TYPE,ALL NFOndA TJOA) -Date: City or Town of: V To the lnspeCt0r Of fflipes., By this application the undersigned gives ve.q notice,of'his or her intention to perform the electrical work described below. Location (Street&Number) Owner or Tenant \ \\\ Ar N Ch- rn Owner's Address _ �17111epb—on,No-Z0io Is this permit in conjunction with-a building permit? Yes ❑ No (Check Appropri,"Ite Box) Purpose of Building Utility Authorization ExistingService— Amps Volts Overhead 1:1 Undgrd n No, of Meters New Service — Amps —Volts DverheadEl UndgrdF] No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CoMletion of thefiollowin fable may be waived by 117e Inspector 0 ..es. No.of Recessed Luminaires No.of Cefl.-Susp,(Paddle)Fans No. of Total No.of Luminaire Outlets Transformers- YA No. of Hot Tubs Generators ICVA No.of Luminaires Swimming Pool 0 o imergency ignan No.of Receptacle outlets ff, 1. grnd. Bli c, te Units 6 No. of Oil Burners FIRE ALARMS No. of Zones No.of Switches No, of Gas Burners No. of Detection and i Initiating Devices No.of Ran-es N Total o. of Ali-Cond. Tons No. of Alerting Devices No.of Waste Disposers Heat Pump Number_JTR�, No. of Self-Contained Totals: . .......... ............ No. of Dishwashers Detection/AlertingDevices Space/Area Heating 1()Ai Local R Municipal FA O , No.of Dryers Heating AppliancesConnection Security Systems- No.of Water No. of KW No. Heaters I(W No. of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: OTHER: No.of"Devices o"Equivalent Attach additional detail it'desired,or as required by the Inspector of TT,7res. Estimated Value of Electrical Worlc; .I _ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with IVMC Rule 10, and upon completion, INSURANCE COVERAGE: T_Jnless waived by the owner,no permit forflie Performauceof electrical work may issue unless the licensee provides proof of liability insurance includin.c,"completed operation"coverage or its substantial equivalent. The undersigned dertifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CBECK ONE: INSURANCE FJ BOND [] OTHER 4�— _Tcerfify,.under the pains and penalties of perjure,fha(the 17zfffnlafion on this ap is plication ,& d ue an complete.FIRMNAMEt: ADT LLC DDA ADT Security LIC-NO.: C-172 Licensee: Thomas j. Lee Sigwr6re LIC.NO.: C-172 (IfA_ 0" 'i0ah 'P Address: Bus,Tel.Na "Perh4 L G Alt.Tel.No.. OWN .c. 14'i',s.57-G1,security won;requires l� � tnt ublic Safety Lie.No. • ow, IR SS 00 1779 cense _E required Y Licensee does not haw the liability insurance coverage normally by er/Agent ereb} waive this requirement. I am the(check one) owner ❑f-]owner's agent, S. i ature Telephone No, PERMIT FEE: t '``C"R D® CERTIFICATE OF LIABILITY INSURANCE DATE/2014 /YYYY) 1 OI0812014 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 PHONE AAC No E ____ A/C x� No)_ _ Sunrise,FL 33323 E-MAIL ADDRESS: Attn:FtLauderdale.Certs@marsh.com INSURERS AFFORDING COVERAGE NAIC# 048953-ADT-GAW-14-15 INsuRER A:Zurich American Insurance Company 16535 INSURED INSURER 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 I ADO SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN SR WVDI POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY GLO509589902 10/01/2014 10/01/2015 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES nce)_ _$_ 1,000,000 -_ rre ___,_ _ _ CLAIMS-MADE I_]OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY S 2,000,000 GENERAL AGGREGATE S 4,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 POLICY PRO LOC $ X JECT B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident) $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident S NON-OVvNAUTOS AUTOS ( ) RTY DAMAGE HIRED AUTO S AUTOS ED Perracodenit- UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 10//112015 X wC STATu- OTH- AND EMPLOYERS'LIABILITY __ TO LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N WC 5095898 02 (MA,WI) 10101/2014 1010112015 2,000,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT S ._._ —........---._-- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 2,000,000 If yes,describe under -- - - -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000 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. ManashiMukherjee @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 'Depg.,,lfaentt of��a�l s�ri°� �cczde a s Office of TH.Vesfigatlonsr d 6Q0 Pr�c shington,. , eel Boston,MA 02111 Workers, c ompelasdiorn Insurance A.f'idavilk Flease Fr nt Legftll tf- Mille(Business/Organization/Ind � t Address: c1ty/St �r 'E3 6�\ 0 l``i � one#. ,�¢c:) ate Gip: Are you an employer?Check the appropriate box: Type of project(required): loyer with_\(jGo `. ❑ I am a general contractor and I 6, [1 New construction. 1, f�I am a emp have hired the subcontractors employees(.full and/or part-time).* 7 ❑Remodeling listed on the attached sheet.'-•' 2.❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑Demolition ship and have no employees workers' comp.insurance. 9, []Building addition working for me in any capacity. [No workers'comp.insurance 5• ❑ We are a corporation and its 10•❑Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑Plumbing repairs or additions 3.El am a homeowner doing all work 12[]Roof repairs myself. [No workers' comp. c.152 § (1 4),and we have no insurance required.]i employees.[No workers' 13.F1 Other comp.insurance.required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hira outside contractors must submit anew affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers comp,policy information• c�tn cett etrzployea°tlatcF isFvro'viclr'ng WOYlfers'cotnpev.sntior�irasz t of?ee for t`ry ertlp�oyees l�eloty i�elie�oliey eencljv r ciie itafots7cctiotr. ! : = ; _ ;E: �_ '�fY1,�`:t _.s, u'.'y i,t�:•.y�:v�'O.. -rir=', c._-::sv'.z�p_.;.�:.i=r Insurance Company Name: r 4 =} E `j 4j ell policy#or Self=ins.Lic. . 3 ' l•.n �r.3-t. r°y, - 'ux 09 s city/state/zip, lob Site Address: Attach a copy of the Workers'conapensat?oil 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. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veri-�"ation. Cio lei-eby ceytify-u der thed�aInsln �nn� U II!e<0fieI tIIY ifani the itafotrmadot��rovirlecicrbove is title and co�t�c� Date�- SiQnattlre _1�� F Phone#: � — Offcicri tt�e syrtly. �o not Write itz dais rtrecr,to be completed by city or town official City or Town: permit/License# Issuing Authority(circle one); .1 Board.of Health 2e Building Depaar u:suent S.Cityl—Aar^rrr Clerk 4.electrical I[taspect®r 5,Plumbing inspector 6.Other Contact Person- � Phone#: _