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Home My WebLink AboutWiring Permit - Permits #12850-1 - 10 IRONWOOD ROAD 11/9/2015 Date........ .. ......................... I pOAT/� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................... ... gym ® has permission to perform ......�:.., . . wiringin the building of.........................................`�................................................................... c ... ................NorthAndover,Mass. at . .r.�............................. .... ................... ---- - Fee...... . Lie.No. ..... ..,.... .......... ..................::::::::-................. ! ELECTRICAL INSPECTOR Check# � fl �ommonweafi,?,oft I�a6aachW("1Td -fi ial Use On)),---- O tc permitNo,_ I� M� _ epczrtnzenf o� ire ervice� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank) AP PLICATI*ON FOR PERMIT TO PERFORM ELECTRICAL WOO All work to be,performed in accordance with the Massachusetts Electrical Code(IviEC), 527 CMR 12.00 (PLEASE PRIArT 1N.INK OR T1'PE 4LL.INFORAdAT1OA) -Date: City or Town of: � p <S Z. To the Insvectoi` of Nlir•es•' By this application the undersigned gives notice of his or her intention to perform the electrical work described below, Location (Street&Number) , Owner or Tenant ` . � _ _._�._._.__ �.�...� �. ��.. � .. ` ,� ., t � Telephone No: t r . Owner's Address piw, Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate' Q Purpose of Building Utility Authorization No, Box) Existing Service Amps / Stops Overhead ❑ Undgrd❑ No, of Meters New Service Amps / Volts Overhead ❑ TJndgrd ❑ No. of Meters Number,of Feeders and Ampacit3 Location and Nat ure of Proposed Electrical Worlc: �,.G�' Coin letion of the follornin table niay be upan,ed by the Laspector of)f1ires. No,of Recessed Luminaires No.of Cell.-Susp.(Paddle)Tans No. of Total " Transformers KVA No.of Luminaire Outlets No, of'Hot Tubs Generators KVA No,of Luminaires Swimming Pool Above In- o, o emergency rgurzner end. ❑ arnd• ❑ Batter Units 11 No.of Receptacle Outlets No. of Oil Burners I+IRE ALARMS No, of Zones J No.of Switches No, of Gas Burners No. of Detection and ` No.of Ranges No. of Air Cond. Total Initiating Devices Tons INo. of Alerting Devices No.of Waste Disposers Hent Pump Number Tons ICVSr No. of Self-Contained Totals: ................_....,........,...., ......................................... Detection/Alertin Devices No.of Dishwashers Space/Area heating I(W Local❑ Municipal Connection (Jfhar' No.of Dryers heating Appliances IN, Security Systems,-. G No,of VSrater No.of No.of Devices or E uival n'- heaters IOW Nc.of Data Wiring: Signs Ballasts No.of Devices or Equivalent � No.Ilydrromassage Bathtubs Me,of W10tors Total HP No Wiring: OTHER: No.of Devices or E uivalent Estimated Value of Electrical Worlc: t- Attach additional detail if desired, or as required by the Inspector of Td"fires. „ � r t��'�� (When tequired by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion, INSURANCE O StE A- GE: Unless waived by the owner,no permit for the performazrce 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 [�,�J (Specify:) _'S.e � -T certi p fP I J, pP � fj,.under the pains mzd enalties o er ur r that the hzforniation on this a Iication is,tlwe and complete. 1 FIRM NAME: ADT LLC DBA ADT Security Licensee: Thomas j. Lee LTC.NO.: C-172 Signure / y LIC.NO.: C-172 (Ifapplicable,enter "exempt" 77thelicense number line.) � ._._, Address: \ (C+ CJ(� ,C1��",`� �`�� fp`- Bus. Tel.No, � ? �` 7 f� Alt.Tel.No.. ' i Per A2.G.L,c. 147,s.5 J 61,securrt}'worr<requires I)CI•&d nt ofPublic Safety"S"License: Lic.No, S (>___U J 7_79 .OWNER'S INSURANCE WAIVER: I am.aware that the Licensee does not have the liability insurance coverage normally M required by law. By my signature below,Thereby waive this requirement. I am the(check one) ❑owner Own er/Aent El owner's agent, g _ Signature Telephone No, PE-RMIT FEE:cff S I 1 A "� CERTIFICATE OF LIABILITY INSURANCE FDAT[(MMDD IN loros/2o15 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 _P{A_Hco,tJ4,ENO: a/c Sunrise,FL 33323 EMAIL s__.___ Attn:FlLauderdale.Ceds@marsh.com INSURERS AFFORDING COVERAGE N_A_IC_tt 048953_ADT-GAW-15-16 _ INSURER A:ACE American Insurance Company 22667 INSURED INSURER B:Agn General Insurance Company 42757 ADT LLC 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. ILTR I TYPE OF INSURANCE ADO SUBR POLICY EFF POLICY EXP LIMITS I SD WVD. POLICY NUMBER MG1/DD/YYYY R4dfDONYYY Ai X COMMERCIAL GENERAL LIABILITY 'XSL G27400954 10/01/2015 10101/2016 EACH OCCURRENCE $ _ 2,000,000 CLAIMS-MADE F_X1 OCCUR DAMAGE TORENTED -- PREMISES Ea occurrence _5__ 1,000,000 X SIR:$500,000 MED EXP(Any one person) S PERSONAL $ _ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,000,000 O _......._._. _.. X POLICY n JELOC PRODUCTS-COMP/OP AGG S 4,000,000 OTHER: S A AUTOMOBILE LIABILITY ISA H08865073 10101/2015 10/0112016 COMBINED SINGLE LIMIT S 1,000,000 Ea accident _ I X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY Peraccident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS (Per accident)... S UMBRELLA LIAR CCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE 5 DED RETEt,fTIOfJS S A WORKERS COMPENSATION N'LR C48593318(ACS) 1010112015 I0101/2016 X PER OTH- B AND EMPLOYERS'LIABILITY Y/tJ STATUTE ER ANY PROPRIETOfUPARTNER/EXECUTIVE WLR C4859332A(Tld) 10/O1/2015 10i01/2016 n F_EACH ACCIDE-N-T- $ _ 2'000'000 FFICERIMEMBER EXCLUDL . N/A O (Mandatory in NH) SCF C48593331('NI) 10/0112015 10/01/2016 E.L.DISEASE-EA EMPLOYEE S 2,000,000 If yes,describe under ---- --- DESCRIPTION OP OPERATIONS below E.L.DISEASE-POLICY LIMIT!$ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Town of North Andover Is Included as additional Insured(except workers'compensation)where required by vaiden 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 AUTHORIZFD REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee n 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Conimon.ivealtli of Massachusetts w Department of 1iidustrialAcchlenfs a X Congf•ess Street, Suite 100 12o�taH.-.)i!re 02:zr .2n.r. www.nlllsS.gov/rlia NVorlcers'Compensation Insurance Affidavit:Builders/Contractors/Electrici ins/Plumbers. TO BE FILED WITH THE.PERMITTING AUTHORITY, Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: \ <9 L\ City/State/Zip: ® � � t Phone#: � � q.u_ Are you nn employer?Check the appropriate box: Type of project(required): I.3,1 am a employer with VLOLcmploy,ees(full and/or part-time).* 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[:j1 am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 10 E] Building addition 4.❑I am a hmneowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 1.0 Electrical repairs of additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.0 I am a general contractorand I have hired the sub-contractors listed on the attached sheet. 13,nRoof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ®� e_ 152,y 1(4);and we have no employees.(No workers'-comp.insurance required.) *Any applicant that checks box HI must also Fill out the section belowshowing 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. tContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their %yorkers'comp.policy number. I am an employer that is providing workers'compensation inst ran ce for my employees. Beloit/is the policy and job site it foi ination. Insurance Company Name: G Policy#or Self-ins.Lic.11: Expiration Date: Job Site Address: ��.. �`� ._, City/State/Zip ��:� 5 �� ', a :1 Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date 1). 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I Flo hereby certify under•the pains andpenalties ofpetjuty that the information provided above is true and correct. signature:OA .�i( N' ° Date: -_... Phone M C Official use only. Do not sprite in this.area,to be completed by city or town official. City or Town: Permit/License#. Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerlc 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: