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HomeMy WebLinkAboutWiring Permit - Building Permit - 303 BERRY STREET 3/18/2013 s Date... c.. � .. .............. r10RT/� TOWN OF a NORTH ANDOVER " * PERMIT FOR WIRING mu This certifies that .. �, A`.. ��� , p 19.2f �� i has permission to erfo N' 3 P nn wiring in the building ............................................. at .. .North ........ ..... Andover,M • d Fees r G� I No � ��•��.. .. Mass. ELEt INSPECTOR ,�' Check# of Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy 1p cy Occupancy and Fee Checked dectriclan's Coll# - contract#& [Rev. 1/071 (leave bLd���� 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 PPJNT IN INIC OR TYPE,ALL INFORMATION) Date: CRY Or Town of. N6r4_ To the Inspector of Wires By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 4, Owner or Tenant. Telephone No. Owner's Address _1�_Appropriate(Chec k Is this permit in conjunction with a building permit? Yes F1 No (CheckAppropriate Box) Purpose of Building Utility,Puthorization No. Existing Service Amps / Volts OverheadFl UndgrdE] No.of�Meters New Service Amps / Volts OverheadEl Undgrd No. of Meters ,N_tfiri_ff6_f bf'1166deis and Ampacity Location and Nature of Proposed Electrical Work. Completion of the folloiving table niay be waived by the Inspector of Wires-. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above F-1 in- 0.0 mergency ig I ng grnd. rud. 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 L Initiatin Devices No.of Ranges No. of Air Cond. Total g Tons No.of Alerting Devices No.of Waste Disposers HeatPumP Nq her._'Yons KW No.of Self-Contained ............................. Totals: Detection/AlertinY Devices No.of Dishwashers Space/Area Heating KW 1,nonl F-1 Municipal F1 Other Connection No.of Dryers Heating Appliances KW Security Syste s:1 No.of Water No. of No. of No.of livalent Heatel's IOW Data Wiring: 81 us Ballasts NO.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP T elecommu rucations Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Vlork. Attach additional detail it'desired, or as required by the Inspector of fllire�y. (When required by municipal policy,) Work to Start:,•,- Inspections to be requested in accordance with MEC Rule 10,and upon CORIPICtiOD. INSURANCE, COVERAGE: Unless waived by the owner,110 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 offlce. CHECK ONE: INSURANCE 0 BOND F1 OTHER X (Specify:) Self Insured IcePlifY,wilder tlzep(iiiisaizdpeiialliesofl,7eijury,that the lizf . .oz orz this application Is frue and complete. FIRM NAME: ADTLLCDBAADTSocurity 1 LIC.NO.: C-172 Licensee: Thomas J,Lee ignature (If applicably, enter "exempt"in(lie 11, LIC.NO.: C-172 erase number une, 0.:.60 0 2N, �3 CL LnTeyv. 1�0 \vS., Akuu) k-t. Address: Bus.Tel.N * Alt,Tel.No,: Security System Contractor License required f6r this work;if applicable,enter the license number here: 001779 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)❑11 owner Owner/Agent [I owner's agent. Signature Telephone No. [PERMIT FEE: o V-VI -:.�::�s��:�4?11S�M41V(E�Ir'�'I�emu=Ill�:��as��:�g I�.€�'E'i��,.•�" •' u a1�� CIrIoU�� iJt),rtt lA��x`iu�fy�t loj�'InUrQlr,�.. ;.,.., . 'ELECTRICIAN5.... . . `At REGISTERED SYSTEM-CONTRA T'O IS$UC-S.i HE 48pVE LICENSE Td. IADT' L;:L.C• D-BA ADT SEC�RZTY Tk1OMAS J LEE.. ' rQ, 4� p :LCr[IVERSITY AVEJ GdE`STWOOD MA 0209,0-23I1.. "=y 172 C 07/31/13 201934 JCjjgg7.fi(o} 1A1(/y�i1C b91J�1I i(:3//�I�l�l .. _ . . t'-old,:fhcn Ualech Along All-Pariar dlons r A��® CERTIFICATE OF LIABILITY INSURANCE DATE(11101/2012MM/D YYY) 012 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: _ 1166 AVENUE OF THE AMERICAS PHONE 7t,6 AX ._(AIC No,Ext) ...._.__.........._—. (A/C NoL..---.. NEW YORK,NY 10036 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC__#__ 048953-ADT-MAIN-12-13 INSURER A:Zurich American Insurance Company 16535 INSURED American Zurich Insurance Company 40142 ADT LLC INSURER e 18 Clinton Drive INSURER C:_ Hollis,NH 03049 INSURER D INSURER E: INSURER F: COVERAGES _ CERTIFICATE NUMBER: NYC-006524016-01 _ REVISION NUMBER:1 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 L'E TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP R INSR I WVD I POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY GLO 5095899-00 09/28/2012 10/01/2013 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000 PREMISESffa-occurrence $ CLAIMS-MADE lxl OCCUR MED EXP(Anyone person) S 10,000 PERSONAL&ADV INJURY S 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 4,000,000 ] LOCPOLICY PRO- $ X AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ ANY AUTO BODILY INJURY(Per person) S ALL OWI4ED SCHEDULED -.-.... - AUTOS AUTOS BODILY INJURY(Per accident) S HIRED AUTOSI NON�OWNED PROPERTY DAMAGE S AUTOS Per accdent)___ S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESSLIAB _ CLAIMS-MADE AGGREGATE S DED i RETENTIONS S B WORKERS COMPENSATION (WC 5095897-00(Deductible) 09128/2012 10/01/2013 X VVC STATU- OTH ` AND EMPLOYERS'LIABILITY YIN TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE �WC 5095898-00(Retro) 0912812012 10/01/2013 2000000 OFFICER/MEMBER EXCLUDED? ❑N N/A E L EACH ACCIDENT S _. (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 2,000,000 If yes,describe under ---- --j —_--—_-----_ — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT ;S 2,000,000 c i I I i i i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE INSPECTOR OF WIRES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 124 MAIit ST. ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Cynthia Y.Kim ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD