Loading...
HomeMy WebLinkAboutWiring Permit - Permits #13235-1 - 3/30/2016 I Date.... ..' � OF r10RT� w►�- ° 'TOWN OF NORTH ANDoVEn I y :=;:.<.:•,> ERMIT FOR � '°•,;.o M..�� WIRING 88�CHUB�t This f certifies that t ... has peissio n to perform ��� �g¢ � a ................... @ C 3 �' .........................I............. whin � _... g m the building of. -\ LI �� n ......... E ..... ...................................... is Fee ,North Andover,Mass. I ...................... Check# ....... Che crRic ELE AL INSPECTO �.o,nnwnweail't`l•oll I�adeachweffi Offi ial"Use 0 _. -- c nlv� --. Permit No, f epa,lmenG`0 4re erviced h BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Chec]ced [Rey 1/07j (leave blank) APPLICATI'ON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 C1YLR 12.00 ( , { F) Date: PLEASE P�7T INW�'OR T1'P.� Z , �'~' �.. To the Inspector Ci or Town of: ��. PO. AdATION By this application the undersi ned tv) her intention p for of 1fli7^es; g g es notice o"fhts of tention to perform the electrical work escribed below, Location (Street&Number) Owner or Tenant :. - f�plmo'_ne No:Owner's Address � o - Is this permit in conjunction with a building permit? Yes El No n ICI (Check Appropriitte Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ IJnd rd g ❑ No, of Meters New Set-vice Amps / Volts Overhead❑ Undgrd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical'Work Completion of the followin [able ma,be waived br the Inspector of Wires, No. of Recessed Luminaires No.of Cell.-Susp, (Paddle)Tans No, of Total 1„ No. of Luminaire Outlets No. of Hot Tubs Transformers KVA Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ 0, 0 rmer., rgntzng rnd. arnd, Batte Units No.of Receptacle Outlets No,of Oil Burners TIRE ALARMS No, of Zonesi No.of Switches No, of Gas Burners No Detection and I Initiating Devices No.of Ranges No, of Air Cond. Total . Tons Initiating of Alerting Devices No.of Waste Disposers Heat Pump Number........ Tons Kph' No. of Self-Contained Totals: ................_... .... , ......................................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KIN Local❑ Municipal Connection 0 OfhPr No.of Dryers Heating Appliances "ISecurity Systems:* No.of Devices or E uivalen't No.of 1'1 atct• No.ofNo. •• "�° Heaters Imo' as Data Wiring: Signs Ballasts No.of Devices or Eauivalent No.Hydromassage Bathtubs No, of Motors Total HP Telecommunications Wiring: No.of Devices or E OTHER: uivalent Aflach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work:Ai �Iv fE (When required by municipal policy,) Work to Start, w,,„��, °" — • Insp ctions to be requested in accordance with NEC 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 dertifres that such coverage is in force,and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE ❑ .BOND ❑ OTHER [� (Specif Icerti p fP J J, } ) certify, the pains and penalties o er ury f1tal the b formation on this application is true and.complete: TIR.MNAME: ADT LLC DBA ADT Security •-�� i •!� LIC.NO.: C-172 Licensee: Thomas J. Lee j — Signure �r� -z -- LTC.NO.: C-172 (If applicable,enter "exemgC' •n the license number line.) ,�_._._. / t_ Address: \ ' Cl(\ � . !'�� 'C U~>C) `{Q Bus. Tel.No, Alt.Tel.No.. �'� ��� -�� 'Per M.G.L.c. 1471,s,57-61,security wore requires))qY&M nt of.Vublic Safety"S"Li ense:c Lic,No, SS 00 l 7.79 .OWNER'S INSURANCE WAIVER: I am.aware that the Licensee does[to[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, PRIIZIT FEE: '_ i AC R 1® CERTIFICATE OF LIABILITY INSURANCE OATE(IA Nil20105 YYY) �,,,�� mos12o15 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)mLlst be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may regUire 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 - _ FAX 1560 Sawgrass Corporate Pkyry,Suite 300 (A/C, Exn: — WC No)_ Sunrise,FL 33323 E-MAIL Attn:FtLauderdale.Certs@marsh.com ADDRESS: INSURER(S)AFFORDINGCOVERAGE NAIC4 048953-ADT-GAW-15-16 _ INSURER A:ACE American Insurance Company 22667 INSURED ACT LLC INSURER B:Agri General Insurance Company 42767 — 18 Clinton Drive INSURER c:ACE Fire Underwriters Cc 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, AODL SUB_ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD I POLICY NUMBER Mh11DD/YYYY) fhiMlDDNYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY '!XSL G27400954 ,10/01 015 10/01/2016 EACH OCCURRENCE l ___ _$ 2,000,000 CLAIMS-MADE M OCCUR DAMAGE"l0 RENTED I PREMISES Eaoceurtencej $ 1,000,000 � X SIR:$500,000 MED EXP —— (Any one person) $ -.... __ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4.000,000 X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: A AUTOMOBILE LIABILITY ISA H08865073 10101/2015 10/01/2016 COMBINED SINGLE LIMIT Ea acadert $ 1,000,000 ) _ ANY AUTO BODILY INJURY(Per person) S ALL ON44ED SCHEDULED BODILY INJURY Per amldent $ AUTOS AUTOS ( _ ) NON OWiJED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) 3-.. UMBRELLA LIAR OCCUR EACH OCCURRENCE S _......_ EXCESS LIAR- CLAIMS-MADE AGGREGATE $ -- --- DIED F2f_TEPRIOr4 S S A WORKERS COMPENSATION N'LR C48593318(AOS) 10101/2015 IN0112016 < PER I oTH B AND EMPLOYERS'LIABILITY STATUTE_L_. ER ANY PROPRIETOR/PARTr4ER/EXECUTIV YIN E VI LR C4859332A(TN) 10101/2015 1NO1/2016 ; i Ft EACHAGCIDEh1T $ 200000D C Or ACER/MEMBER EXCLUDED? N N/A ....- __.. - (Mandatory in NH) SCF C48593131('NI) i0/O1/2015 0i0112016 F.L.DISEASE EA EMPLOYEE S 2,000,000 If yes,describe under - - - --..-. ----- - ---. .....___ DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT S 2,000,000 DESCRIPTION OF OPERATIONS[LOCATIONS I VEHICLES (ACORD 101,Addltlonal Remarks Schedule,stay be attached if more space Is required) Town of North Andover Is Included as additional insured(except worke rs'compensalion)where required by millen conlracl. 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. idarlh Andover,Iv1A 01845 I AUTHORIZED RFPRESEt4TATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(20-14101) The ACORD name and logo are registered marks of ACORD I. The Commonweaftli of Missaelzuselts x Department of111(lustrial ecirlents I Congress Street,Suite 100 ix�stan,-MA;- 2.rr��2n.r.7 www.mass.govIdia ' �S`ot'Iters'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers, TO BE FILED WITFI TI•TE.PERIv ITTING AUTTIOATT'1', Applicant Information Pleas 1 e Print Ise is bly Name(Business/Organization/Individual).' � tr Address: City/State/Zip: d Vt �i Phone#: �'1" U Areyou an employer?Cheek the appropriate box, Type of project(required): I.0,1 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.[]1 am s sole proprietor or partnership and have no employees working for me in S, C(Remodeling any capacity.(No workers'comp.insurance required,] 9, ❑Demolition 3.[j 1 am a homeowner doing all work myself.(No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a he 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 solo 11.[]Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,F]Roofrepairs These sub-contractors have employees and have worke..rs'comp,insurance.t 6,Q We area corporation and its officers have exercised their right of exemption per MGL a 152,§1(4);andwe have no employees,(No workers'•comp.ins urancerequired.] *Any applicant that checks box#I most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name oI'the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their tyorkers'comp.policy number. P am an employer that Is providing worlcets compensation insurance for my employees, Below is the policy r nd job site it formation, Insurance Company Name:_ Policy#or Self ins.Lie,#: 'vim�-�.& 1���' ��� Expiration Date: t�- Job Site Address: : s ttion n rlaati n_ page stso vira� tietptreijecy Zlp ember and exp..anon.date), Attach a copy of the tivoi I(ers compen a ,olicy P g ( b 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. X do hereby certify under fire pains and penaltt`es of petjttt;}i that the information provided above is true and correct. Date ~ -- — St nature: „,�.•. ..A �,..°C .. " — Phone# ® F ial use only. Do not Yvrile in tltis area,to be completed by city or town officialor Town: Permit/1License#.ng,Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerlt 4.Electrical Inspector S.Plumbing Inspector 6.Otlier Contact Person: Phone#: