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Home My WebLink AboutWiring Permit - Permits #13234-1 - 18 DARTMOUTH STREET 3/30/2016 Date.... .............�....... ........ OF µORT/.�7ti TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that ... has permission to perform ` ....................... wiring in the building of �� e ............ ..... North Andover,Mass. Fee ........:....................Lic. No ..... ......................................... ELECTRICAL INSPECTOR Check# ... C f 11� � al- se on)), -- - olnmonwea t�.o� andac zudeLG6 FOccupancy O�et UBOARD OF FIRE PREVENTION REGULATIONS d Fee Checked eave blank) APPLICATI'ON FOP, PERMIT TO PERFORM ELECTRICAL � ORK All work to be performed in accordance with the Massachusetts Electrical Code(IvIEC), 527 CMR 12.00 (PLE'1S'E PRINT IN INK OR TI'PE.fILL.INF01aL4TJOA9 Date: City or Town of: . O, �.�,� ` ". ti • g � ��• �� .,P To the Iizspector of Wires,, Y PP gives notice of his or h B this a licafron the undersi ned form the electrical work described below, Location Street&Number ,M 1 ( � to perform m , � intention ion Owner or Tenant .., �':` ---- <., ?:, Owner's Address TelephoneNo: Is this permit in conjunction with a building permit? Yes ❑ No ' (Check Appropriate Box) Purpose of Funding Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd ' g ❑ No, of Meters New Service Amps / Volts Overhead" ❑ Undgrd ❑ No, of Meters Number of Feeders and Ampaeity Location and Nature of Proposed Electrical Work: - `� r Com letion of the followin table nia,be a wined by tlae Inspector of Wires. " No. of Recessed Luminaires No.of Ceil.-Susp. (Paddle)Fans No. of Total Transformers '""� No. of Luminaire Outlets VA `x Na.of Hot Tubs Generators K I�VA No. of Luminaires Swimming Pool Above ❑ In- ❑ a• o rmezgency rgnring Lrnd. arnd• Bette Units No.of Receptacle Outlets No, of Oil Burners .FIRE ALARMS No, of Zones No,of Switches No. of Gas Burners No, of Detection and _ Initiating Devices No.of Ranges No, of Air Cond. Total INo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ICE No. of Self-Contained Totals: ..,.. , ... .•......................................................... Detectio /Alerting Devices No.of Dishwashers Space/Area Heating I{W L Municipal ❑ Connect on ocal on N Ofhar No.of Dryers Heating Appliances ILIA' Security Systems:* No.of ater No.of Devices or E uivalent )... . No. of ;• Heaters I No.as Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No, of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent C; ilttach additional detail if desired,or as required by the Inspector of Tflires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start ` `"w:,;; '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 of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned dertines that such coverage is in force,and has exhibited proof of same to l the permit issuing office, CHECK ONE: INSURANCE ❑ BOND ❑ OTHER d (Specify:) _43"t'_`1�- ictic I certify,.zcnder the pains and penalties of perjury,,that the h formation on this application is.twue and.complete: FIRMNAME: ADT LLC DB.A ADT Security Licensee: Thomas J. Lee LIC.NO.: C-172% Sign ure /� -(Ifapplicable,enter "exempt" 'n the lice se number line.) ,� / c_ LIC.NO.: C-172 Address: _ \'� C`o r, gyp(\ S'< �*\C34�� 3'�C'C 4 Bus. Tel.No, -Y—�-� Alt.Tel.No..Q`,_ J I G `Per n4.G,L.e. 147,s.57-61,security wore requires Dgyattc�nt ofOublic Safety"S"License: Lic.No, SC C'JO J 77� OWNER'S INSURANCE AY, I am.aware that the Licensee does 17ot 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 ❑ owners a, cut, Sigrratur e Telephone No, PE-R MYT FEE: D ` � .. ' , AG U�� DATE(Mh9/DONYYY) �,. CERTIFICATE OF LIABILITY INSURANCE 10106/2015 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 pollcy(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 Ilea of such endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME: --- 1560 Sawgrass Corporate Pkwy,Sulte 300 _{a/o moo,EMU: _..-._____.�Fq Sunrise,FL 33323 - ALADDRESS: tin: t auderdale.Cerls@rnarsh.com -- -- INSURER(S)AFFORDING COVERAGE NAIC it 048953-ADT-GAW-15-16 INSURER A:ACE American Insurance Company 22667 INSURED ADT LLC INSURER B:Agfl 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 WTH 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY FEE POLICY EXP LIMITS INSD WVD POLICY NUMBER MMIDDNYYY l4M/DDNYYY A X COMMERCIAL GENERAL LIABILITY XSL G27400954 110101,2015 10101/2016 EACH OCCURRENCE_ $ 2,000,000 D MAGE TO RENTED _ --- CLAIMS-MADE X OCCUR PREMISES Ea occurrence___ S 1.000,000 X SIR:$500,000 MED EXP(Any one person) $ I PERSONAL&ADV INJURY $ 2,000,000 GENE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 j X POLICY�J JE C LOC PRODUCTS-COMP/OP AGG S 4,00,000 OTHER: S A AUTOMOBILE LIABILITY ISA H08865073 10/01/2015 10/01/2016 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accidert) -_ —-- _ X ANY AUTO BODILY INJURY(Per person) S j ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON OWNED PROPERTY DAMAGE 4 AUTOS (Peracddenl) UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS MADE] AGGREGATE $ f2ETENTION$ A WORKERS COMPENSATION WLR C485933 18(AOS) 0/01/2015 IN01/2016 t T PER o1H B SAND Eh1PLOYERS'LIABILITY STATUTE i ER ANY PROPRIETOR/PARTNER/EXECUTIVE WLR C4859332A(TN 2,000,000 ) 10/0112015 1001/2016 EACH AC CIDerdT $ 0 OFFICER/MEMBER EXCLUDED'? NIA - -- - (Mandatory in NH) SCF C48593331(' L I_M) 10/0112015 10101/2016 E.L.DISEASE-EA EMPLOYEE S 2,000,000 It yes,describe under --.-_- ---- --- ----- DESCRIPTION OF OPERATIONS bolow I I I F I DISEASE POLICY LIMIT S 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be alrached if more space is required) Town of North Andover Is Included as additional insurod(except wiorkers'compensalion)where required by written conlmcl. CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTId',Flectrical Inspector THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 124 Main St. ACCORDANCE WITH THE POLICY PROVISIONS. lcrlh Andover,MA 01845 All 1 HORWFn REPRESENTA FIVE of Marsh USA Inc. Nlanashl Mukherjee 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i The Con2mmnwealtli of Massaeliusetts / x Department of 1rztlustrialAecitlents I Congress Street,Suite 100 ,�ta�^.n!��02.zrd 2n..r.7. „M www.mass.gov/dia ' '""ot'Icers'Compensation Insurance Affidavit:Builders/Contractors/Electt•icians/Plumbers, TO BE FILED WITH T1-1E,I ERrvIITTING ALIT%1OMTY. Applicant Information Please Print Legibly ff �4 9 Name(Business/Organization/Individual): � �1— — `i \ �� _ Address: VX, R R �e city/state/zip: �.� �� f�� Phone#' - Areyou an employer?Check the appropriate box: 'Type of project(required): L3tiiamaemployerwith .,Gt;(3`�'`� employees(fulIand/orpart-time).' 7. ❑New construction 2.[,]I am a sole proprietor or partnership and have no employees working for me in 8. F]Remodeling any capacity.(No workers'comp.insurance required.] g, [1 Demolition 3.Ej 1 am a homeowner doing all work myself(No workers'comp.insurance required.]t ]O F]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property, twill ensure that all contractors either have workers'compensation insurance or are sole 1 1.[]Electrical repairs or additions proprietors with no employees. 12,Q Plumbing repairs or additions 5.[]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.nRoofrepairs These sub-con tractors have employees and have worke..rs'comp.insurance.[ 14. Other 1_..ra o,-1 6.0 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.] N` <=d tom, *Any applicant that checks box fil must also rill 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 a new affidavit 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 subcontractors have employees,they must provide their tyorkers'comp.policy number. I am an employer that lsproviding Ivor/revs'compensation fnstlrance for my employees. Below is tile polley rrndjob site info'rmafion, e Insurance Company Name: ,o � Policy#or Self-ins.Lie.M. ,_ _ , - Expiration Date: �' to iCa fT3StntG,zl t n'Job e ^nt�LYpa ?Oi3 date), Site a copy of t workers' compensation policy declaration page(sho./.n the policy n b � s' ) � � �� " � 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 wclI 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 thepains and penalfies of peljcn);that the information provided above is true and correct. .,> .., Si nature:ei Dato. a — 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 CIerlc 4.Electrical Inspector 5.Ptnmbing Inspector 6.Other Contact Person: Phone 4: