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HomeMy WebLinkAboutWiring Permit - Permits #12320 - 572 FOREST STREET 4/28/2014 N Date °... �...�................ o�acarH�ti ? ;.. TOWN OF NORTH ANDOVER n PERMIT FOR WIRING BgaCHUSE This certifies that . .. C ...b¢. ��b . ... ....... has permission to perform ' ........ ., .. ....... �...�. wiring in the building of... .."...r . ° ..... at r F�, k � 5E e North Andover,Mass. t.,........ ............. r.. .. No 'A Fee .....,, ...I. Lic.N6 Al . ..,`,D �'EL�CCRICAL INSPECLOR �_ Check# Commonwealth of Massachuseffs offficial Use 0aly 6epartmeng of Firo ServIces Pormityo' BOARD OFFIRCPREVE-Ni[ON REGULATIONS AM Occupancy and lee.Checked (ffeas Izi gzev.11071 a6ava bjank) sonfract 9&bIdgermif 9 if applicaNe, APPLICATIOM FOR PERM-IT TO PERFORM ELECTRICAL WORK AR work to be performed in accorddncz with-the 1,fassachusetts Blectricst Co&(.ivI Q,527CMR12.00 (T-LB.4"mr,PR�VT'wm 0 R Yy-pur'�r'mmmmolv) ))ate. City or ToA d, To the Impector of H-es: By this application the undersigned goilbs notice of his or her intention to Teaformthe ckotdcal work described below. 7'1 C1 '�E Omer's Address fS this permit in coquilctiormith a building permit? Yes ❑ Na NY (Check Appropriate Doe) purpose ofBii-Vdiag_'(Tt!11t7Auffio-nzat;.oA No- CN Ajnp3 Volis Overhead El undgrdEl No,of meters I NeiySerdeq Amps Volts ovorb.6acl FJ Wgrd FJ No.of-Meters h1mber of Feeders and Ampacity LOW10A and Nature of)'.roposecl MedrinlVilork: Compfellon offfiefqZfowt,,g.table may he ipa;vedby thefinspector of W/Yrem j 01 Fn)-of recessed INO.of ccif'S'asp.(.Paddle)Vaus j"NQ. s dotal Transformers formers X-VA biro,of afro Cutlets INO.of Hot Tubs e-)I or a t o r s 11YA Abow. k m gg[I m- , ING.OMergeAcy - t—m No. g of Luminaires IwimmingRool gopid. 0 IF'aff en,Ukilt No.C &1tcheq IN0.of Gas Bianem 000tectiorE and of Receptacle outletg IN6.of Oil Bumers IFIREALARATS I-N1o.0ZZG))'c1 J. No.of - 1 o I I N .0 'a..of Ranges No.of Air Cond. Tons -No.OfAlefting Devices o.of'WastLeDisposers HCARE orts INO.of 6el I xw Jf-Coutabled Tot DeN:Iceg 2> No.of Dfshwasher8 jSpace/Area Aeating XW ILlf--oml EJ F-I Gther Comier ❑on Na,of Dryers attngAp FIecilli—ty S1f!FtV.w—s: liffe p.11Ancles INO�of Delqceg orEqui'laleAt No.of Water Im. NO.Of No.of xPatawhring: Heaters Balrasts No.of Nvices orb uivalen FZ'o,. ydronuassage athtulss No.of Motors �'Otal YE, Tel Na,of"DencesoxlLzvaleut T Fstmnatod Value of Anch acV!1F6wtde;a0ifdw!re4 �-eqvircdby dmrnspector of firesr (WIen required by municip,al policy.) work to staxt.lv"> N I'as-p artions to be requested in accoi:dameD with ME C l3gle 10,and up on completion. LNSURAX CF,COWRAGX: Unless w9v ed by the om ex.-no permit for the p orformaner of cleddeal.-work may issue unless ibc licensee provides proof or its substantial eqiri-valent..*je undersigned certIffogillat such.oolcragois in force,and has exhibited proof of-samato the permit issuing office. CBECK ONE: )NMURANC13 13 BOIND El OMP,X (SpeoWy.) self-insured Ycenify,under that thainforwaffm ait this appHc(itio)ziytriie'and complete. 'MR-11 INAM ADTf LCD)3A ADT 8cGmly C-172 Licensee: Thomas Mee, C-172 y ppikable.enter"armpi"f7l fire license number line: Bus,Tel.No.- Alf"Tel.N 960M1diy System(-'0jjUdUL0rjjCC-T)-q0required wr tuns - rk,if applicable,enter 1ho license number hem: 001779 OWN=S YNMRANIC�WAIVER: I am awara that the,Licensee does not have the liability mismaucc coverage normally TelophmeNoreasenf. S a.m.the(clierk.P.�'Q�`�"�`�d�1 uW �• aT'enL Q� 6 (L DATE(MM/D61YYYY) A�CO�RI7 CERTIFICATE OF LIABILITY INSURANCE I 09/25/2013 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 w certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 'C NAME: AOn Risk Services Northeast, Inc. PHONE FAX 4) Morristown NJ Office (Alc.No.Ext): (866) 283-7122 A/C.No.: (800) 363-0105 "a 44 Whippany Road, Suite 220 E-MAIL c Morristown NJ 07960 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Zurich American Ins CO 16535 ADT LLC INSURERB: American Zurich Ins Co 40142 ADT Security Services 1501 Yamato Rd INSURER C: Boca Raton FL 33431-4408 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570051395419 REVISION NUMBER: 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. Limits shown are as requested I SR TYPE OF INSURANCE ADD S BR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD D/YYYY A GENERAL LIABILITY GL05 5 MM/DDIYYYY MM/D EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1,000,000 PREMISES Ea occurrence CLAIMS-MADE X❑OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,600 PRODUCTS $4,000,000 M GEN'L AGGREGATE LIMIT APPLIES PER: LO X POLICY JEO CT LOC o AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) Z ALL OWNED SCHEDULED BODILY INJURY(Per accident) d AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE U AUTOS Per accident t� d UMBRELLA LIAR HOCCUR EACH OCCURRENCE f..) EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION B WORKERS COMPENSATION AND WC509589701 10/Ol/201310/Ol/2014 WC STATU- OTH- A, EMPLOYERS'LIABILITY YIN WC509589801 10/01/201310/01/2014 X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $2,000,000 OFFICER/MEMSER EXCLUDED? M N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $2,000,000 UDE describe under SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) =6 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ram= TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE ° INSPECTOR OF WIRES9 124 MAIN ST. ^yJ� NORTH ANDOVER MA 01845 USA GXJ��B c..0� 11rtl dVI!!Glr�✓� ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ol MY V We qf" .11firy(lio i f 6 ama sa, ae-ow. u,71 hr, -Campowntlo ro jUs urn F-aec'.AM"IN14s.-N&J"T 9 d-onsf(C,-;�p wn Plprofir k-of.rdeh v0k Fpj in v Af, lkonctilliffifeby. e�. TIM ADTSecurit Services Clinton Drive lie 3- wypoof pyqfcid, you'44 monqdj oyw?CARVOf I . .x ra qg on I G -v"a-Fl,[1,1 I tywloyor wfth—q 0 M�- 4 2,T3 1 ax a, " . - ig, '11, g• fr ollg Ell"BuilcRug U40 w G VVIV suo'a wd u-.T� herumm"we ifla's f -.T) TL ysfi,[No my jA and 131,61TV,[go wow- Security.System V.who,vA5lMR Dadlob Off"R'M.ey-if smzak mad Mom,Wa-oupz&4 gvemcrnp xmvt tubv-Wk a afridalvit hdibuldiggr 5 IIQI,, -1 ofill a.that cbff,�,R.1 & faveAlF P Zurich American Insurance Co. 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