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Home My WebLink AboutWiring Permit - Permits #13232-1 - 110 FARNUM STREET 3/30/2016 ,a Date :f)CJ. ............. r►ORTH � TOWN OF NORTH ANDOVER m PERMIT FOR WIRING sBACHUs�� This certifies that _� e' VA ................................................................................................. erform ...p �`�.. f..... �.... � ...- ` ................................ has permission to wiring in the building of......... at ........ ..� ..............North Andover Mass. Lic.No. Fee ..... ..•............ :................ ...... ELECTRICAL INSPECTOR Check# k I o�nrnanweaGvt� l'j� - - t•a a dac aueiGe OTC' U el h 'r „ e7parlmtint<o�'�' Permit No, � � ire erviced BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Pee Checked [Rey 1/071 (leave blank) DPP LICATI'ON FOR PERMIT TO PERFORM ELECTRICAL �� All work to be performed in accordance witli the Massachusetts Electrical Code(Iv1EC), 527 CNm i 2.00 (PLEASE�rT N NK OR TYPE ALL FOR,AdATJOA9 -Date: City or Town of: � " � ," �i „��.,""1�:"/',, �, To the Inspector of TT ties; Location Street cG Number) — �wG to perform the electrical�rorlc described below. Y application g g her intention.. this a rcatian the undersi ned fives notice of his or Ads • an Owner or Tenant .... . t w, Telephone No: Ct_:�: :°°p Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No nn ' VJ (ChecT(Appropriate Box) Purpose of Building Utility Authorization No, Existing Service Amps / Volts Overhead ❑ Und rd❑ No, of Meters t Now Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: " 4w f .w, �, Com letion of the followin table to be waived by the Jnspector of Wires. No. of Recessed Luminaires No.of Cell.-Susp. (Paddle)Fans No, of Total Transformers KYA No. of Luminaire Outlets No. of Hot Tubs Generators IVA ' No.of Luminaires Swimming Pool Above ❑ In- o, o emergency rgnnng wind. arnd, ❑ Bette ,Units ' No.of Receptacle Outlets No,of Oil Burners hIRE ALARMS No. of Zones No,of Switches No, of Gas Burners No, of Detection and - Initiating Devices No.of Ranges Total No.of Air Cond, 'Pons No. of Alerting Devices No.of Waste Disposers Heat Pump )Number Tons ICVF No. of Self Contained , Totals: ,.. .................................... No, of Dishwashers Detection/Alertin Devices Space/Area Heating IOW Local❑ Municipal Connection Qfhar No.of Dryers Heating Appliances KW Security Systems:* b No.of later No.of Devices or E uivalent •,,.:°, No, of Heaters KW Ballasts Data Wiring: No. of Si us alts No.of Devices or Equivalent "" No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: y� OTHER: No.of Devices or E uivalent Estimated Value ofElecttical Wor)c ilttach additional detail if desired,or as required by the 1t7spector of Tflires. :,UP ES(', r (When required by municipal policy,) Work to Start \( Inspections to be requested in accordance with MEC Rule 10, and upon completion, INSURANCE C0)7ERAGE: Unless waived by the owner,no permit for the Performance of electrical work may issue unless the Iicensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent, Tile undersigned dertifres that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specify:) t �lG eic� 1 certify,.under f/zepains andpenalfles ofperju.7Y,that the 17 formation on this application is.true and complete. I+IRMNAME: ADT LLC DBA ADT Security LIC.NO.: C-172 ' Licensee: Thomas J. Lee Signure �i t -- LTC.NO.: C-172 (Jf applicable,enter "exempt"(17 the license num__ber line.) ,( / t_ Address: \ \;c� vt� `�� Bus. Tel.No, �tfc;®' 4 C . C1`fir .��.� Alt.Tel.No *Per M.G.L.G.L.c. 141,s.57 OI security wore requires bqg nt o• ".Vublic Safety"S"License: Lie,No,.. S'.S (9U 1779 .OWNER'S INSURANCE)VAIVER: I am.aware 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) ❑owner Owner/Agent Signatu El owner's event, re . Tel epin oil eNo, �' PERMITF.&'E.• '_ i C a : '... a zo® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/06/2015 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 staternent 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 PHONE'Exit: FAX Ne _. -- - - Sunrise,FL 33323 qp-ADDRESS: Attn:Ftlauderdale.Certs@marsh.com --- INSURER(S)AFFORDING COVERAGE NAIL IF 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: _ I 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 TYPE OF INSURANCE SRT ADDL SUER POLICY EFF POLICY EXP WSD W BD POLICY NUMBER ht1d/DD/YYYY MM/DO/YYYY LIMITS A ': X COMMERCIAL GENERAL LIABILITY XSL G27400954 110/0112015 10101/2016 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE O OCCUR DA RAGE TO RENTED — PRFMISES Eaowurrance $ 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 $ 4,000,000 PRO- ___..__—.... _X POLICY JEGT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 T OHER: _... S _ _— A AUTOMOBILE LIABILITY ISA 1108865073 10101/2015 10/0112016 COaMBINaccidert)ED SINGLE LIMIT g 1,000,000 E X_ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY Per accident $ -- AUTOS AUTOS ( ) NON OWNED PROPERTY DAMAGE - HIREDAUTOS AUTOS (Peraccidenl) S $ UMBRELLA LIAR OCCUR '', EACH OCCURRENCE $ EXCESS LIAR CLAINIS MADE AGGREGATE- $ DED RETENTION S $ A WORKERS COMPENSATION AILR C48593318(AOS) 10/01/2015 10/01/2016 X PER orH AND E.IPLOYERS'LIABILITY YIN _ 1_STATUTF ER _ B ANY PROPRIETOR/PARTNER/EXECUTIVE WLR C4859332A(TIJ) 10/01/2015 1OX 1/2016 OFFICERIMENIBER EX,CLUDED7 l IJ/A _E.t_EACH ACCIDENTS - 2,000,000 C (Mandatory in NH) SCf C48593331('Ail) 1010112015 10101/2016 E.L.DISEASE-EA EMPLOYEES 4000,000 If yes,describe under -- .-.._.------------ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIN11T!,S Z000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Town of f,lorth Andover Is Included as additional insured(except vrorkers'compensation),/here required by vaitlen contract. CERTIFICATE HOLDER CANCELLATION Town of Dlorth Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:Electrical Inspector THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IN Main St. ACCORDANCE WITH THE POLICY PROVISIONS. iJarlh Andover,MA 01845 AH I HOR17H)RFPRESENTATIVF 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 Pninionwettlti2 ofll osachusetts r Department off. i(lustrial echlents l Congress Street,Suite 100 I www.mass.gov/dia ' '"'or"Icers'Compensation Insurance Affidavit: Builders/Contractors/Electrleians/I'lumbers" TO BE FILED WITH T14E.P ERMITTING ALITI-109ITY, Applicant Information Please Print Lc� Name(Business/Organization/Individual): Address: 3 City/State/Zip: 1 `�� a 0t a � Phone Areyou an employer?Check the appropriate box, 'Type of project(required): 1.0,1 amaemployer with „GLr73J� employees(fulland/orpart-time).* 7. �, Now construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. rj Remodeling any capacity.[No workers'comp.insurance required,] g, D Demolition 3.01 am a homeowner doing all work myself(No workers'comp.insurance required.]t 10[l Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will I 1 [1 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12,n Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,F]Roof repairs These sub-contractors have employees and have worke,rs'comp.insurance.* . 14.['LOtherlV,3 �Mt 6.F]We area corporation and its officers have exercised their right of exemption per MGL c, t 152,§1(4);and we have no employees.[No workers'-comp.insurance required.] *Any applicant that checks box#I must also Fill out the section below showing their workers'compensation policy information. t Homeowners who subnit this affidavit indicating they are doing all work and then hire outside contractors must submit a newaffidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of'the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their tyorkers'comp.policy number. I am an employer that Is providing worl(elsI compensation insurance for my employees. Beloly is file policy and job site i1 fo?niatioll. i Insurance Company Name:_� _® ��CO ' Lr �• '+ � Policy#or Self-ins,Lic.#: ` q Expiration Date; Job Site Address <� .t � " C t ",w City/State/Zip ",� � Attach a copy of the workers'compensation policy declarat4on page(showing the policy ntimberand expiraffor fla to Failure to secure coverage as required under MGL c. 152,1 §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 mdy be forwarded to the Office of Investigations of the DIA foi•insurance coverage verification. I do hereby certify under-tilepalns andpenalties of peljlllf't/lat 1/1e 111forniation provided above is true and correct re. � � �.. � ,... ,. i . r t St natup� � Date�- Phone#' Official use only. Do not write 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 ClerIt 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: