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Home My WebLink AboutWiring permit - Building Permit - 61 GRANVILLE LANE 8/3/2015 Date NONT�y E � •'• °o� TOWN OF NORTH ANDOVER * 1 * PERMIT FOR WIRING CHU This certifies that ..• qpq � �� J'....... .................Y.. ... ................................................... ....... has permission to perform Y1 � , wiring in the building of..,,,,,,, ........ ........ at ....... � tl� , ....... , ohAndover,, Mass. Fee Lic.No.(.,' ... ....SPECTOR............................. LECTRICALIN 1 Check# 4+ 10znmonWea LY.o/i!1 aaea.c� - c l Use only �� ; � acr�r.CGS � O,iicta J • i C L .) ,... C Perm it No. _ _ �epar�tznvnt o� ire�ervicee BOARD OF FIRE PREVENTION REGULATIONS Occupanc} and Pee Checked [Rey 1/07] (leave blank) APPLICATI'ON FOR PERMIT TO PERFORM ELECTRICAL WOO All work to be performed in accordance with the Massachusetts Electrical Code(MEC), S27 CMR 12.00 (PLEASE PRINT IN IMK OR TYPE,ALL.1NFORM4 TIOA) Date: Cite or Town of: �� ' "'�i 0' " ,�_ To the.Inspector of Whiies;By this application the undersigned gives notice of his or Location (Street&N hei intention to perform the electrical work described below. Number-) � �; Owner or Tenant , ---- Tel plioneNo: '0 ., , Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No �❑ (Check Appropriilte Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / •Volts Overhead❑ Und rd g ❑ No. of Meters Number ofFeeders and Ampacity i Location and Nature of Proposed,Electrical Wor•lc e N µ 4 Completion of the folloit+in table mar be waived big the Inspector of 1flires. No. of Recessed Luminaires No, of Total No.of Cell.-Susp. (Paddle)Fans Transforrriers IVA No. of Luminaire Outlets No, of Hat Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o, o t'mergency ignnng grnd. urnd, ❑ Batter its No.of Receptacle Outlets No, of Oil Burners FIRE ALARMS No, of Zones No.of Switches No, of Gas Burners No. o�f Daec�tion and Irt� itiatingDevices No.of Ranges No. of Air Cond. Total Tons �No. of Alerting Devices No.of Waste Disposers Heat Pump Number...T..•.... .....•....Totals: ............... .. Contained Detection/Alerting Devices No.of Dishwashers Space/Area heating ICW Local❑ Municipal [ Connection 0 0 t"'r• No.afDryers Heating Appliances IOW Securitysystei No.of Water No of No.of Devices or E uivalent Heaters ICE No, of Data Wiring: Signs Ballasts m° No.of Devices or Eauivalent • No.Hydromassage Bathtubs No.of 11'Iotors 'Total HP Telecommunications Wiring: N, OTHER: No. -Device or Equivalent Estimated Value ofE)echical Worlc; ,dt[ach additional detail if desired,or as required by the Inspector of T3"ires. _ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with Iv.>EC 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 certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER 0 (Specify:) I certify,,under tine pains and penalties of pezjuz),,that the hr fornzatlon on this application is, r>ze and conzplefe. 1 FIRMNAME: ADT LLC DBA ADT Security �`.. !� LIC.NO.: C-172 Licensee: Thomas j. .Lee � - LIC.NO.: C-172 • Sign�ui•e / ,�/�. (Ifapplicable,en[er "exemq!" 'n fhe licetnse num er line.) K . / t_ 1- Address: \ ' �� rU(\ �js Bus. Tel.Naj C3`�.\ U Alt,Tel.No.. "'Per M.G.L.u. 147,S.5 J-61,security woric requires OCT&C( ent ofPublic safety "S"License: Lic•No,OWNER'S INSURANCE WAIVER: I am.aware that the Licensee 5-3 Up 17'79 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/Agent ❑ owner s agent, Signature Telephone No, P-ERIIZIT.FEE: S, t aco CERTIFICATE OF LIABILITY INSURANCE DATE 10108/2014 /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 PAHONnEo Ext: FA/c No): _ Sunrise,FL 33323 E-MAIL Attn:FtLauderdale.Certs@marsh.com ADDRESS: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR I WVD POLICY NUMBER MM/DD/YYYY /Y MMIDDYYY A GENERAL LIABILITY GLO509589902 10/01/2014 10/01/2015 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000 PREMISES Eaoccurrence $ _ CLAIMS-MADE � OCCUR MEDEXP(Anyone person) _ $ 10,000 PERSONAL BADV INJURY $ 2,000,000 GENERAL AGGREGATE S 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A_GG S 4,000,000 X POLICY E PE O LOC S B AUTOMOBILE LIABILITY BAP 5095900 02 10101/2014 10101I2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Pidt $ AUTOS AUTOS (Per accident) HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS Per acadent S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTIONS $ B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 10/01/2015 X I S STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER _ A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 5095898 02 (MA,W) 10I01I2014 10/01/2015 2,000_,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ ___ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE S 2,000,000 If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD tot,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 .i�e�1f�PZr'lytte�lZ aruraccc?�Rrc 9.r�� u Qfjtce of Invesd9t1i Ons d 600 PTIt'shMV09Sireel i Boston,PIA 02111 oR1a savvg Vwl -Mass-go-plafltr Worken, corape-Usatlorn Insurance Affidavits J[��n��de>�/cC��A°��®>r� '4�T1epse I'Ant Log bl A Ilekt11nforination Na171 e(Business/Oxgauization/Ind R1uQl)% city/Stale/Zip: =5; Are yore au erraployer?Check tine appropriate box: Type of projeet(required): 4, ❑ I am a general contractor and I 6, ❑New corrsfruction- 1. I am.a employer with. ?. - have hired the sub-contractors employees(.full and/or part-time,).* 7. Remodeling listed on the attached sheet.'' Demolition 2.❑ I am a sole proprietor or partner- These sub-contractors have 8 ship and have no employees workers' comp.insurance. g° []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 1•❑Plumbing repairs or additions right of exemption per MOL 1 3111 am a horrieovrner doing all work and we have no 12.❑Roof repairs myself. No workers'comp. c.152, §1(4), t ern to cos. oworkers' cnr, \(c�� insurance required,]� p y � Other��- comp.insurance required.] MAny applicant that checks box#1 must also fill.out tha section below showing their workers'compensation policy information. Homeol}ubers who submitthis affidavit indicating they are doing all vvozk and then hire outside contractors must submit anew aifdavit indicating such. Contractors that check this box must attached an additional sheet showilig the name ofthe sub-contractors and their workers'comp.policy information. Ctr'r2 lEti e7rLj7r0J1e1°t Zltj ES roviding workers'e0liTensa ion insT ranee for W eftT10yees: Below is#1e.POliey c?ncijob sue inforin ation. t r j' <•A-, y :,#PF-� E' �=�;9<(�ir3�::::y f'(�`• �a '- -saves;' - -� Insurance Company Name: .. = - :Policy 4,�-or Self-ins,Lic.#: N�-. �.r�}t3 `- . �• s � � City/State/'Zip: Yob Site Address: (r � "� '`� \i° policy declaration (slroviing tllre policy number and expiration date).Attach copy el tho Workers' corarperrsatiora al penalties of a Failure to secure coverage as required under section I1 aMGv G.penalties in the form of a STOP WO j�ORDER and :line fine up to$1,500.00 arld/or one-year imprisonment, p of up to$250.00 a da against the violator, Be advised that a copy of this statement may be forwarded to the Oti"rce of y Ines tigations of the DIA for insurance coverage verV:-ation. rlo/iereby ceyto- -tin ler0ed-in_irlslfillSpe11aaIfie�f p er,/ttry t1iat t1ie iiafoYYufEiota�rovitlericr6ove is Trice and cofrec� Date: SiQnaftire��• -_- — ' F Phone : Official arse ortiy. Do not Mite its zliis r�rerr,co be corrTleted by city or fowrx ofj rcial City or Town' A ermit/I,ice�se ik Issuing AMhorffy(circle one): 4.Board,of ealtla 2�Building Department 3.City/,Aawn Clerk 4,Electrical 111spect0r 6,Flu-mbirrg 1-rspector 6,Other 'hone 9: Confaca Forson� l