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HomeMy WebLinkAboutWiring Permit - Permits #13200-1 - 221 FARNUM STREET 3/21/2016 f Nowrti Date o • .J..J... Tp * * WN Oiz NOnTH . » pER� A NDpVER CHusE �1C� This certifies that to Perform e hasPermission _' •�� �;�• �. so I rzn d� wLnn the build' 0 p g of jII at t� ti_ ° ... ... . _ ... Fee ............. � . ic,No. ......,North Andover,M .s.... _m ss Check# ELECTtu CAL INSPECTOR....................... i - // 1fl1�1. �/ 7/ i:�.OIYLmAl2weaGL�.of /�a;fJac/iu3etG`��� - � F[Rov. -- • r Official-Use Only yy cc`yy� No. - �JeparEtnznt o� ire erviced ncy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 7) (leave blank) APP LICATI*ON FOR. PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with file Massachusetts Electrical Code(1v1EC), 527 CMR 12.00 (PL—V4 E PRINT IN-1NK OR TXPEALL WFOkkmT10J1) 'Date: B this application the undos: ned ivP— ekofh�s m hey intention — �` � To the Inspector of I'(lir^es; Y pp .g g to perform the electrical work described below, �...,, N Own erorTenant � ��� � ---- -- �� a°- Location (Street cC u � a , � Tel� ephone No. 1 Owner's Address � Is this permit in conjunction with a building permit? Yes ❑ No Q (Cheelc Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / 'Volts Overhead ❑ Undgrd❑ No, of Meters Nevi,Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters Number of I+eeder•s and Ampacity Location Nature of Proposed Electrical and Na p ecrcal Worlc: Com letion of the followin table map be waiiled by the h7spector of Tdrh•es. No. of Recessed Luminaires No.of Ceii.-Susp. (Paddle)Fans o, of Total Transformers KYA No. of Luminaire Outlets No, of Hot Tubs Generators RVA a No. of Luminaires Swimming Pool Above ❑ In- o,tey Units o t'rnergency ignung No. of Receptacle Outlets No,of Oil Burners Qrnd, Bat . �rnd. ❑ �FIRE ALARMS No, of Zones No.of Switches No. of Gas Burners No.of Detection and _ Initiating Devices No.of Ranges No, of Ali-Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Num}�er Tons IgA. No, of Self-Contained Totals: ......... ................ . .....•.........•......................... Detection/Alertin Devices No.afDishwashers Space/Area Heating IOW Local Municipal ❑ Connection Ofhpr No.of Dryers Heating Appliances IOW Security Systems:' No.of VI ater No, No.of Devices or E uivalent IOW of No -,.. Heaters . of Data Wiring: Suns Ballasts No.of Devices or Eauivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail 1f desired,or as required by the Inspecto,•of Tflires. Estimated Value of Electrical WorllCpspections to)_�� (When required by municipal policy.) Work to Start „ be requested in.accordance with MBC 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 certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ElBOND ❑ OTBER (Specify:)S�' �'� I certify,.-under the pains and penalties of perjury,that the information on this application is,ttue and complete.' i PIRMNAME: ADT LLC DBA ADT Security ''______--_.....,� /� •-''� LIC.NO.: C-172 ` Licensee: Thomas Lee �— LIC.NO.: C-172 Signure / / . (If applicable,enter "exemRC' 'n the licepse num er hneJ �_._._, / c_ Address: _\�' [�\; Bus. Tel.No, " Per A2.G.L,�. 14�,s,57 G1,security work requires Jet�dment. Alt.Tel.No �� t� � t� OWNER'S INSURANCE WAIVER; I am.aware o�(�ublic Safety "S"License: Lic,No... SS UU / 779 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)❑oN�mer ❑owner's agent. Own er/Agent Signature Telephone No, R-R76171T7FEE-1 _ o _� CERTIFICATE OF LIABILITY INSURANCE DATE(r2 10/06/201 DO YYYY) 5 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 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 Ifeu of such endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME: (F 1560 Saw+grass Corporate Plevy,Suite 300 PHONE Ext_- �FAX No Sunrise,FL 33323 ADDRESS: Attn:FtLauderdale.Cer(s@marsh.com INSURER(S)AFFORDING COVERAGE NAIC S 048953-ADT-GAW-15-16 _ _ INSURER A:ACE American Insurance Company 22667 INSURED INSURER B:Agri General Insurance Company 42757 ADT LLC 18 Clinton Drive INSURER C:ACE Fire Underwriters Cc 20702 Hollis,NH 03049 INSURERD: 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. I�TR TYPE OF INSURANCE RT ADOL SUER POLICY EFF POLICY EXP INSD WVD POLICY NUMBER Acid/DD/YYYY fAA1ID0/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY iXSL G27400954 10I01/2015 10/01/2016 EACH OCCURRENCE___ $ 2,000,000 CLAIMS-MADE O OCCUR DAMAGE TO RENTED PREMISES Ea occurre $ 1,000,000 nce X SIR:$500,000 _ MED EXP(Any one person) $ PERSONAL&ADVINJURY S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,OOD,000 X POLICY❑PRO- ❑LOG _...._ JECT PRODUCTS-CO,MP/OP AGG $ 4,000,000 OTHER: $ A AUTOMOBILE LIABILITY ISA H08865073 10101/2015 10101/2016 COMBINED SINGLE LIMIT S 1,000,000 Ea accidert _ X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per $ - AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE S _._ AUTOS (Per account) S UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS_-MADE AGGREGATE $ DED RETENTIONS 5 A WORKERS AND EMPLOYERS'LIADILCOMPENSATIOI ITY WLR C48593316(ADS) 10/01/2015 I0I01/2016 X STATUTE EORH B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A VIII.R C4859332A(TN) 10/01/2015 101D1/2016 F f,EACH ACCIDENT $ 2,000,000 OFFICERIMEMBER EXCLUDED? C (Manda(cry in NH) SCFC48593331(WI) 1010112015 10/01/2016 E.L.DISEASE-EA EMPLOYEE S 2,000,000 If yes,describe under _—.._..._..._—_. __...—_......—......_... DESCRIPTION)OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be all ached if more space Is required) Town of North Andover is Included as additional Insured(except workers'compensation)where required by written 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 AUTHORIZFD RFPRFSENTATIVE of Marsh USA Inc, Manashi Mukherjee ©'1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Common wealth ofMassachusetts / Department of liztlustrialAecklents X Congt-ess,S'treet,Suite 100 _ w xz t�.—!M,02114 69.7 www.mass.gov/dia ' '",ovi(ers'Compensation Insurance Affidavit:Builders/Contractors/Electt•icinns/Plumbers, TO BE FILED WITH THE PE RMITTING ALITI 091T1'. Applicant Information Please Print Le ibly Name(Business/Organization/Individual): V � — Address' _fi c Phone M Wo s City/State/Zip: FAO W 's V Are you in employer?Check the appropriate box; Type of project(required): I,i �t am a employer whit C7f1� employees(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. FIRemodeling any capacity.[No workers'comp.insurance required,] 9, []Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[-]Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will I 1 I ]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole L_1 p proprietor's with no employees. 12,F]Plumbing repairs or additions 5.®1 am a general contractorand I have hired the sub-contractors listed on the attached sheet. 13,F]Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. t 152,§I(4);and we have no employees,[No workers'-comp.insurance required.) Any applicant that cliecks bo.\#1 mostalso rill out the section below showing theirworkers'compensation policy information, I fi Homeowners who submit this affidavit indicating they are doing al I work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, ifthe sub-contractors have employees,they must provide their �yorkers'comp.policy number. ' 1'am an employer that isproviding wor/revs'compensation insrirance for my employees. Below is firepolicy ondjob site lnfiormatlon. e Insurance Company Name:-C--!_ qA_M�_ Policy#or Self-ins,Lic.#: ` ,_ F � ` Expiration Date: � } x��¢~. �� �> a. 73 w, city/s Job Site Address. t t , "� ^��tV ration .a e/shoevin� hetutol y n rn gel and expiration dot Attach a copy of the woi l(ers compensation policy de_la p g b e 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, 1 do hereby certify under the pains and penaltles of peijun that/Ire information provided above is true and correct. ... { Date: Si nature: �'�t4 s .. — Phone# � " r ficial use only. Do not write in this area,to be completed by city or town official.ty or Town: Permit/JLicenseuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Toavn Cleric 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: