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Home My WebLink About- Permits #13233-1 - 41 HAWTHORNE PLACE 3/30/2016 Date. ............. �NORrhgtio TOWN OF NORTH ANDOVER i PERMIT FOR WIRING i ,gBACHUgk II i ' a This certifies that has permission to perform .... . "' wiring in the building of....... .......Q y North Andover,Mass. . .. , at .......... >.................. Fee......- .................. Lic.No i ................NSP................................. ELECTRICAL INSPECTOR Check# �UUAZ t �onnnnonweakli o(�Jf�addacliudeCGd" Official Use Only — �Jepar�ttnenf f7i� C Permit No. �°z, �° I o t-e.J erviced BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rey 1/07] (leave blank) APPLIC ATION FOR PERMIT TO PERFORM' ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC)(PLB , 527 CMIt 12.00 INF�ORAdATJOA9 "Date: m ASE PRINT ININIL OR Tt PZ'A,. � T ALL Cityof o of: ..� To the lnspectot• of g it es; Location Street�Number , ( )g g s notice ofhrs or Y Pp het retention to perform the electrical vvorlc described below, this application the undersigned rv. y Owner or Tenant _--.... '. �, Telephone No, Owner's Address �. ., Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate 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 of Feeders and Ampacity Location and Nature of Proposed Electrical Worlc: 1 Com lesion of the followin sable map be wahn by the Inspector•of Wires. No. of Recessed Luminaires No.of Ceil.-Susp• (Paddle)Fans No, of Total Transforxrrers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o.o rmergency rgnung LTrnd. grnd• Batten,Units No.of Receptacle Outlets No. of Oil Burners PURE ALARMS No• of Zones ------- No.of Switches No. of Gas Burners No,of Detection and IuitiatinQ Devices No.of Ranges No. of Air Cond. Total Tons �No.of Alerting Devices No.of Waste Disposers Heat Pump Number To ICV4' No. of Self�Containetl T ....... ... ....... otals: . . . ........ ......................................... Detection/Alertin Devices No.of Dishwashers Space/Area Pleating K'�)' Municipal Local ❑ 0 Connection ft,pr No.of Dryers Heating Appliances r Security Systems:r °" KV w:No.of lriratcr No.of Devices or Equivalent Heaters IOW No.of No. of Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No,of 1wotors Telecommunications Wiring: Total HP g: No.of Devices or E uivalent OTHER: a� A11ach additional detail if desired,or as required bj,the Inspector of Wires. "c, Inspect ons to µe — (When required by municipal policy,) Estimated Value ofElectrt al Work: _ Work to Start A)� "„.LL � '," • " b 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 licensee provides Proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned dertifles that such coverage is in force,and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specif),:) I certify,.under tine painns and penalties of perjure,that the it formation on this application is Niue arzd complete: FIRM NAMt: ADT LLC DBA ADT Security ---''�"'r •� LIC.NO.: C-172 P Licensee: Thomas J. Lee % Signure �-� -- LIC.NO.- C-172 (Ifapplicable,enter "exempt" 'n 117e license num er line.) ,(_,___ _ _ Address: \ �`;c., Cpn ��<- \r '�! Bus. Tel.No, '�� Alt. Tel.No..C � Per M.G.L.c. 147,s.5 J-61,security work requires l�t�r. t nt ofQublic Safety"S"License: Lic,No. SS UO J 7'7� {OWNER'S INSURANCE, 1VAIV[R: 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 'Owner/Agent )❑ _ ❑ owner s agent, Signature Telephone No, PERMIT.FEB . a , A�"� CERTIFICATE OF LIABILITY INSURANCE DATE(/ YYY) tOt06120152015 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 pollcy(fes)must be endorsed. if SUBROGATION IS WAIVED, subject to the terns 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 ileu of such endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME: 1560 Sawgrass Corporate Pkwy,Suile 300 AICN o Ext)__-_ FAX No)_______ Sunrise,FL 33323 ADDRESS:I Attn:F(Lauderdale.Cer(s@rnarsh.com -- - _ INSURER(S)AFFORDING COVERAGE _NAIC 11 048953-ADT-GAW-15-16 INSURER A:ACE American Insurance Company 22667 INSURED ADT LLC INSURER B:Agri General Insurance Company 42757 -- — 18 Clinton Drive INSURER C:ACE Fire Underwriters Co 20702 Hollis,NH 03049 INSURER D: INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003446293-04 REVISION NUMBER:4 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 ADD L SUER POLICY EFF POLICY EXP LTR: TYPE OF INSURANCE INSD WVD. POLICY NUtd BER MRi/DDNYYY h4dIDD/YYYY LIMITS A , X COMMERCIAL GENERAL LIABILITY XSL 101010015 10101/2016 I G27400954 I EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE �)OCCUR DAMAGE TO RENTED 1,000,000 — PREMISES Ea occurren ce) $ X SIR:$$500,000 _ IdED EXP(Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY O j� Cl LOC PRODUCTS-COMP/OP A.GG S 4,000,000 j OTHER: S A AUTOMOBILE LIABILITY ISA H08865073 1NO1/2015 10;01/2016 COMBINED SINGLE LIMIT S _ _1,000,000 tEa,acciderti — X ANY AUTO BODILY INJURY(Per person) S ALL AUTOS AUTOS SCHEDULED BODILY INJURY(Peraccident) $ NON OVNAJED PROPERTY OAMAGF _ HIRED AUTOS AUTOS ..(Per acpdent). S ' I S UMBRELLA LIAR OCCUR EACH OC.CURRDICE _ t EXCESS LIAR __- -— - - CLAIIAS-MADEj AGGREGATE ., DED RETENTIONS A WORKERS COMPENSATION WLR C48593318 AOS) 1010112015 1NO1/2016 X )PER OTH- B AND EMPLOYERS'LIABILITY ( __STATUTI _ER _.. ANY PROPRIETOWPARTNER/EXECUTIVE Y N WLR C4859332A(TN) 10/0112015 1NO1/2016 �r r EACH ACCIDENT I S 2,I7Q0,000 C ,OFFICER/MEMBER EXCLUDED? I� NIA - - (Mandatory in NH) ISCF C48593331('NI) 10/0112015 IOI0112016 F L.DISEASE-EA EMPLOYEE$ 2,000,000 If yes,descnbe under ...- DESCRIPTION OF OPERATIONS below C L DISEASE-POLICY LIMIT S 2,000,000 I I I DESCRIPTION OF OPERATIONS I I-OCATIO14S I VEHICLES (ACORD 101,Additlonal Remarks Schedule,may be at(ached If more space Is required) Town of North Andover Is Included as additenal Insured(except workers'compensation)eAlere.required by written conlrecl. 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 SL ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 018d5 All THORtzeO RFPRESEHTA TIVE or Marsh USA Inc. i Manashi Mukherjee OL 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD " The Coninionwealtli of Massachusetts z .Department of 1iarlustrialAceMents X Congress Street,Suite 100 { www.nwss.gov/dia ' ^N wovi(ers'Compensation insurance Affidavit:Buiidez•s/Contractors/Electrieians[Plumbers, TO BE FILED WITH TI-IEYERMITTING ALITY-109ITv. Applicant Information Please Print_LegiblY 1 Name(Business/Organization/Individual): Address: �,�' �..�, �,�, 0� City/State/Zip: 1 ('"c,�, r hone P Are you nn employer?Check the appropriate box, `type of project(required): L ,,,I am a employer with ,GtltrJ employees(full andlor part-time).* 7. [ New construction 2•❑1 am a sole proprietor or partnership and have no employees working for in 8. Remodeling any capacity.(No workers'comp.insurance required.] 9, U Demolition 3.[j 1 am a homeowner doing all work myself(No workers'comp.insurance required.]t 10 r]Building addition 4.❑I am a homeownerand will be hiring contractors to conduct all work on my property. I will 11,[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are solo proprietors with no employees. 12,F]Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F]Roof repairs These sub-contractors have employees and have workers'camp.insurance..-' " 14.K Other L_,,�?a,-1 6.F]We area corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4);and we have no employees.(No workers'-comp.insurance required.] G ti St *Any applicant that checks box#1 most also fill out the section bclowshowing their workers'compensation policy information• t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name ot'the sub-contractors and state whether or not those entities IlaVe employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing)Pothers'compensation insurance for my employees. Mott'is the policy rrnd job site information. e Insurance Company Name_= � ..ac F 1 ` �, Q : " Policy#or Self ins.Lie.#: \r^ , Expiration Date� :�� F — — , Job Site Address: °., � � � t wing Zipntt> be , t; g d f� D' e "�, C / .. t Attach a copy of the 1vorlcers'compensation policy declaration page(slto,.rn y e�oar$10 Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement mdy be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of peDjiu;l,that the information provided above is trite and correct. b Signature: ." f Date .-..,D Phone# � Official use only. Do not write in this area,to be completed by city or tolvn official. City or Town: Permit/License#. Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerlc 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Ph one