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HomeMy WebLinkAboutWiring Permit - Permits #13201-1 - 5 FERNVIEW AVENUE 5 3/21/2016 Date ' z" 0 f►ORTM, TOWN OF NORTH ANDOVER f 9 ' * * PERMIT FOR WIRING 88gCHUg�� This certifies that -4 ................................................................................................................... has permission to perform � ,.;-4 ...... ...................... wiring in the buildingof. �� 0 �k (Vti3 .... ...... ............................ ............................North Andover,Mass. Fee. . ..................Lic. No. ELECTRICAL INSPECTOR Check it r Ofci "Use 0 1p _ • --- ... �--�mon.wea �7.O//(�ad6aC/iGtdetZd.. -' �� _ epartrn of o�l Pcrmit No. ire ervicee BOARD OF FIRE PREVENTION REGULATIONS IONS Occupancy and Fee Checked " [Rey 1/07] „ (leave blank) .DPP LICATI*ON FOR PERMU TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CMR 12.00 PLEASE PWITIN.INKOR TYPE ALL WFOIAd1T1OI1) Date: y application or' the n of:g ed , P� Q " ion t To the 177spect07' of*hires.' B this a lieation the undersr n g notice of his or her intent o perform the electrical`work described below. Location (Street&Number k.- °.. w. z .. ,..__�t �-Tele hone No`: 4'.' .,� ,, w,. Owner or°Tenant °""` � , 4 C "' d ry Owner's Address p r Is this permit in conjunction with a building permit? Yes ❑ No (Check Appr•opri nn ' �J Purpose of Building Utility Authorization No. ate Box) .Existing Service Amps /`Volts Overhead ❑ TJndgrd❑ No, of Meters Neva Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location dand Nature of Proposed Electrical Worlc: p Com letion of the follovnin table may be waived by the nsocator of YPires. No. of Recessed Luminaires No.of Cell.-Susp. (Paddle)Fans No, of Total Transformers KYA No.of Luminaire Outlets No, of Hot Tubs Generators KVA No. of Luminaires Above ❑ In- ❑ o, o emergency rgnung Swimming Pool ffrnd arnd Batter Units No.of Receptacle Outlets No. of Oil Burners IrIRE ALARMS No, of Zones No.of Switches No, of Gas Burners No. oo Deteection and - Initiating Devices No.of Ranges No. of Air Cond. Total — Tons INo.of Alerting Devices No.of Waste Disposers Heat Pump NuTb.er' Tons ICVV No. of Self-Contained Totals: .... . .' Dete tion/Alerting Devices No. of Dishwasliers Space/Area Heating KVir Local❑ Municipal Connection OttiPr No.of Dryers Heating Appliances K-01 Securi' Systems:* -�• rw No.of 1r1 ater Im, No.of No.of No.of Devices Heaters Si or E uivalent ms Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No, of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Altach additional detail if desired,or as required by the Inspector of f�f/Wes. Estimated Value Electricalof Work.- (When required by municipal policy.) Work to Start; w Inspections to be requested in.accordance with MEC Rule 10, and upon completion, INSURANCE, COVERAGE: Unless waived by the owner,no permit for the performance ofelectrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specify:)'` ' C1�ic c; I cerfify,.under the pairzs and penalties of perjug,that the 17zforntatlon on this application is fi•cte and.complete.' 1 FIRMNAME: ADT LLC DBA ADT Security -�'"�� ;-- •� LIC.NO.: C-172 ' Licensee: Thomas J. Lee Signrure / /�. �- "-- LIC.NO.: C-172 (If applicable,enter "exemgt" 'n the license num erhneJ �_, / t_ Address: \ -y Bus, TeI.No, . �C3 t\��'�t� �,��' 1 Alt.Tel.No..l. 'Ter M.G.L.c. 14/7,S.57 G1,security worn requires bt rr OWNER'S INSURANCE WAIV79 LR: I am.aware that tile e Liceant�ee daes nat have the liability insurancec. coverage(normally 7, required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner Owner/Agent ❑owners a ent. Signature Telephone No, PER11TrT FED ' u_ AC`OR�® CERTIFICATE OF LIABILITY INSURANCE --TEIIA 10106120152015 YYYY) 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 poilcy(les)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: O FAX 1560 Savlgrass Corporate Pkwy,Suite 300 AHCC No,EX0: A( /C,No): Sunrise,FL 33323 Ao RIESS: Attn:FILauderdale.CeOs@marsh.com - INSURER(S AFFORDING COVERAGE NAIC N 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 ADDL SUBR POLICY EFF POLICY EXP LT R TYPE OF INSURANCE INSD D POLICY NUMBER MM/DD,YYYY) (IAM/DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY IXSL G27400954 11010112015 10101/2016 EACH OCCURRENCE $_ 2,000,000 CLAIMS-MADE a OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) S 1,000,000 X SIR:$500,000 MEDEXP(Any one Person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,000,000 PRO- OTHER: JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: S A AUTOMOBILE LIABILITY ISA H08865073 10101/2015 1010112016 COMBINED SINGLE uMIT $ 1,000,000 Ea accidertl _ X ANY AUTO BODILY INJURY(Per person) S _ _. ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NONOWN,ED PROPERTY DAMAC'E HIRED AUTOS AUTOS - $(Per $ UMBRELLA UAD _[� OCCUR _EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COP,1PENSATION WLR C48593318(ADS) 10101015 IN0112016 X PER OTH- B AND EMPLOYERS'LIABILITY YIN N STATUTE ER _ C ANY PROPRIETOR/PARTIIIERIEXECUTIVE Y I N/A NLR C4859332A(TN) 10/01/2015 10101/2016 E .EACH ACCIDE14T $ 2,000,000 OFFICEFVMEMBER EXCLUDEU7 f — (Mandalory in NH) SCF C48593331(NI) i010112015 10101/2016 E.L.DISEASE-EA EMPLOYEE S 2,000,000 If yes,describe under 2,000,000DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Addltlonai Remarks Schedule,may be attached If more space Is required) Town of North Andover 1s Included as additional Insured(except workers'compensation)where required by wriden 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 018,15 AUTHOR2FD REPRESENTATIVE of Marsh USA Inc. Manashi MUkherjee ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Conrhaonwealfli of MassaMusetts x Department of. 1m1ustrialAccNeMs I Congress Street,Suite 100 un°fo"3 n ,92rr.� www.n7asssgovldia W'ovl(ers'Compensation Insurance Affidavit:Builders/Conti,:actors/Electricians/Plumbers. TO BE rlLri3 WITH T14E,.PERNIITTING AL)TH091T 1. Applicant Information PIease Print Legit Name(Bus iness/Organization/lndividual): Address: r a ,�.� �Q � City/State/Zip: Phone#}_�® �`` t Are you nn employer?Chcclt the npproprfnte box: 'Type of project(required): 1,131 am a employer with ,ad 1 employees(full and/or part-time).' 7. ❑New construction 2.[]l am a sole proprietor or partnership and have no employees working for me in 8. r(Remodeling any capacity.[No workers'comp.insurance required.] g, D Demolition 3.[j 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10(l Building addition 4.❑1 am a homeownerand will be hiring contractors to conduct all work on my property. twill I 1 n Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3,F]R.00f repairs These sub-contractors have employees and have worke'-rs'comp.insurance.« I4.®Other L..t°rW 6.Q We are a 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.] *Any applicant that checks box 91 must 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 ofthe 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. 1'am an employer that Isproviding 3por/fees'compensation insttrance for my employees. Befoty is thepollej<andjob site info'rrnation. 4 Insurance Company Name:= ivy ® c�C� Policy#or Self ins.Lic.#: Expiration Date: �� � w v C] /States Ztp `�"1 Job�iheuAdodre®f the tivorlte compensation policy declaration Page f vin he policy n umber and c�ra or;date), r r f PY p 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 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. 1 do hereby certify under the pains and penaltles of perjury that the information provided above is trite and correct. Signature:UA_,A,;r? � ..����.�"; � Dat � e. ... Phone#: Official nse only. Do not write in this.area,to be completed by city or tolvn official. City oi-Town: Permit/.License#. Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerlt 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: