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HomeMy WebLinkAboutWiring Permit - Correspondence - 193 GRAY STREET 11/24/2014 Date.......... ............................ ' aoRril TOWN OF NORTH ANDOVER PERMIT FOR WIRING * �� '0- ��,...=••-+�,;.'erg i ,88gCHUs . Lb, This certifies that � .. ... P ,�'� $ � p p ........ .."...: `...... ...:.� .... .................................. has ernussion to erform g wiring in the building of M� j ... -at .......... . .� .....` F... b t= 'N.................................................. dover,Mass. t orth An Fee �� a €��� a LI� ..........Lic.No ..... ......<.... .... ............ ELECTRICAL INSPECTOR :.( i Check# �, I Commonwealthof Massachusetts 0r1 ' So 0 Department of Fire,Services BOARD OF FIRE PREVENT'ION REGULATIONS Checked 'icy and Fena Occupai God6s &hl (leave blank) APPLIQATION FOR PERM''IT TO PERFORM ELEGTRICAL WORK M'work to bapmfomod in ncord?nce Code X�Q,527 C-AdR 12,00 or Toyv� gnTd (j%,— 0 47e Inspecto qf Tf,7pes. r BY this applioatio-a tho undex-si o V,('st v e e'I OTIm�x or T:eximit p, 's O'Maeeo Address Tele X'q mis perrait in C;;ialzctiov'54th a b'0116lig Parm F't? Yr--s dry (Cilectc Appropriate)Sox) '(10ity hithonzailoxi Not E�dsi eb19Se,-;T6ca_ Amps I Volts OverheadFl unagrd El Lgeff S'endre Amps s (—Voug ov.,rb.6 a a El slodgrd[J of Feederq and A-impacity Lotation and Natare of Ixop osed 3gectriejj V11 CO??'PkIfOrx 0ff1Yaf0M010,-,g table 7Pfy. he iPq.Wdbv theynspeclor of T-11irds. No.of Recossea Lumillaireg No.of Ceif.,SWT. NJo-,'r' Tzamfoxmers X-V.A NO,Of No.ofHot'rabi 107A Ai)a Y-G- No.of 1'11�nalreg S)Viraming-Pool -Y r'-d. El 1 0 �mbjrgency 1zc tin- I e�MIR'S lVaw of-Raceptacle 0-Atleft No,,of fill Burixors I I FIRE MAPlvms—K'�o, lino.of smvches- a o f N-reclao.'a,anal INO'of Gas.Birmerg NO-.of Rauge.s No.of Air coxtd. ions -No.of M q'tiAg D Mc es fop of rite 13ispasers Heat'PUMP Nimber I Tons I:KW nT o,oflS1-11,Coz*razetl jerb gDevice'- No.of)Djshv;ash6r8 (),jace/Axaakleathig KW M-11)A ipz[ C F1 other No,of Dxpers HeatiugA.pplianees cctixilp 1 ys e. s. No.of Iya- r . No.ofDevlm�or'v' xvi No.of DataWWrto- :ffeafers I NO,of BI;4ces or ftivafent Si. n Baffinl��s I Blydroroa-'qmge�afhtabs NO,.of il"'roforg 'rofal He, alvalmt 01V7zen roq*od by xannicipal policy) work fo start, WMRAX-CE COW,RkGrl,.- Ualesg valved by tbo o�mr;,XID Peullit for&MPOrfoxroalaco of oleddral-workmayissDq rmle.ss, the licensee provides proof of liability iusurncP,jholudir).g or its substantial eqirivale.xrt, 'jCho roj&rsigijed cortiHeg-.q,4at such,coverago is in force,and has o\'M- bzted Proof ofzarap to the permit issuing offiro. CMCKONF: )NSOTRANICE DOND E] OTT-1 R X (Spaojfy.) FIRI&XINAAM. ADTLLCD)3AADMGimt3, cewee. Thomas L Lee siggy a(�-r6 Vi XTC.NO— C-17-9 ad applicable'.entei,-expmpi in-Tia license nwnbej Address: TO. t5courity'systero.6)4�"Idx-Llcens Us work;if apl: '4a Tel. o requkc-a lior'j �h a erhe-ro: 001779 6VM-RW-S)W8TJT,A1\'CFMWBqR: lam awaza-thatthaLicamoo does riot have the liability insurance Coverage normally 'XeTihred bylaw. Byroy signa-have below,I hereby waive this xoqaircmout .1 am,flt8(ofieck One)Q oi%er Ej ojv'16r,s agge.nt FE, AC"o® 10108/2014 CERTIFICATE OF LIABILITY INSURANCE DA TE /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 Saw rass Corporate Pkw,Suite 300 PHONE FAx 9 Po y _-(A/C,No Ext): _. AIC No), Sunrise,FL 33323 ADDRESS: Attn:FtLauderdale.Certs@marsh.com - - --- - — _ INSURER(S)AFFORDING COVERAGE NAIC# 048953-ADT-GAW-14-15 INSURER A:Zurich American Insurance Company 16535 INSURED American Zurich Insurance Company 40142 ADT LLC INSURER B 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 LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY GLO 509589902 10/01/2014 10/01/2015 EACH OCCURRENCE S 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence S CLAIMS-MADE M OCCUR MED EXP(Any one 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 POLICY PRO LOC S X JECT B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accidentS X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS Per acadent S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTIONS $ B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 10/1112111 X i W�srATu- oTH- AND EMPLOYERS'LIABILITY --TORY LIMITS ER _ _ A Y/N WC 5095898 02 (MA,W) 10/01I2014 10I0112015 2,000 000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E. EACH ACCIDENT S (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 2,000,000 If yes,describe under 2.000,OPO DESCRIPTION OF OPERATIONS below _ _ j F I DISEASE POLICY LIh41T j S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD T11e Conimonweclth ofl'✓assiichpsetts Depcartnrent of Industrial Accidents w office of Investigtitions d 600 Washington Street Boston, MA 02111 4 p��plp�+�r /y/P O,�IY SYvv wwwer�ecassogovAlia Workers' tCornpensatio n ffnsulrance Affidavit: l�nnnJlaeks/��ntn�et®ns/ +�e�t>rn�n�nit�/JE'��ln�l��rrs flneannt �ti Name (Business/Organization/1ud�iduol)� e?<'�� Address: \•� �.'_\t 5� �•c��4`� �. �, City/State/:Zip: �Ao s s t'-1 VV` 'hone#: � Are you an employer?Clreck the appropriate box.: Type of project(:required): 1.M-1 am a employer with_\UrJ0'f" 4, ❑ 1 am a general contractor and I 6. ❑New construction. art-time employees full and/or .* have hired the sub-contractors ( part-time).* listed on the attached sheet. ? 7• ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees `these sub-contractors have 8. ❑Demolition di insurance.' workers comp.insur . 9, Building working for me in any capacity. ❑ g addition o workers' comp insurance 5. ❑ We are a corporation and its [N comp. 10.❑Electrical repairs or additions required,] officers have exercised their exemption per MGL 11.E]Plumbing repairs or additions right of exern 3.❑ 1 am a homeowner doing all work p p c. 152, 1(4), and we have no 12. Roof repairs myself. [Na workers comp. § ( } t employees. [No workers' insurance required.] 1�.( Other E comp.insurance,required.] <H2,—'Z, Sit 5\ � `Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who submit this affidavit indicating they are 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 mfornxatiou. f aiiz an einployei•that lspi'oviditzg worlfeis'cotiipeiisatioiz insiirari.ce for my employees. Below is the policy and job site information. ��.".;: Insurance Company Name: ... Policy#or Self-ins,Lic.#: r3'• .. ,a: z >> krYp tai�arR.Dte ist .� ._ y .. � ��„� ,.. State ,„Al —al W+ y Job Site Address: .. City/State/Zi : Attach a copy of the workers' compensation,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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veria;•'ation. flo hereby ceitify`trrader thepait�;lmura pei2r�lties o peijaaty that the information provided above is trite andcori'eca. Sit3nattlret(..ry'I'V °yam .? s � Date: e T-_ Phone#: Ofj7cial rase only. Do not write in this area,to be completed by city or town official. City or Town: Perinit/License# --- Issuing Authority(circle one): 4.Board.of health 2<Building Department 3. City/Town Clerk 4. IN lectrica9 Inspector �.Pltrza�bing Inspector 6.Other Contact Person: __ Phone#: