HomeMy WebLinkAboutWiring permit - Permits #12435 - 60 BEECHWOOD DRIVE 6/30/2015 ...........
Date...
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING.
CHU
C" ... ... ..........................
................. .........
This certifies that ....................................................
has permission to perform ............................
............ I..............
A- A-
��, ,y�............................... ......................I...............
wiring in the building of..........
?;� e :� North Andover,Mass.
at ...I..........I.-....... ..................
.............Lic.No. ......... ...................................
Fee... . .............. INSPECTOR Check#
Common-weafLii.of /1�aasachwe&— Official"Us On
etvarEmtint S Permit No. '
of ire en4cad
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 (leave blank)
APPLICATI'ONJ FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(iv1EC), 527 CMR 12.00
(PLEASE PRINT ININK OR TFTPE.dLL INFORM,4TJOA9 "Date:
City or Town of; To the Inspector of fi1i7-es;
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number) 60 a
Owner or Tenant - --- — - c
"' Telephone No: , n `3- 1t�
Owner's Address Q
Is this permit in conjunction with n building permit? ]yes f�
❑ No � (ChecTc Appropriitte Box) ^�
'Purpose of Building Utility Authorization No. j
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No, of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Com letion of the fill ta6lenta be tnaired b>>117e Inspector of ld�ires.
No. of Recessed Luminaires No,of Cell.-Susp.(Paddle)fans No, of Total
Transformers T11,
No.of Luminaire Outlets No. of Hot Tubs Generators XVA
No.of Luminaires SwimmingPool Above ❑ In- ❑ o,Bat o (mergency ignting
�rnd. Qrnd, te Units
No.of Receptacle Outlets No.of Oil Burners
I+IRR ALARMS No. of Zones
No.of Switches No. of Gas Burners JNo. of Detection and
• Initiating Devices
No.of Ranges Total No. of Alerting e
Na. of Air Cond, 'Pons b Devices \�
No.of Waste Disposers Heat Pump Number Tons ICR No. of Self-Contained
Totals: ... .......................................
Detection/Alerting Devices
No. of Dishwashers Space/Area Heating K'�)/ LocaI❑ Municipal FA Ofh
Connection er
No.of Dryers Heating Appliances I{yS, Security Systems:*
No.of Water No.of Devices or I uivalent
Heaters IOW No, of No.of Data Wiring:
Signs Ballasts No.of Devices or Rauivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
O THE R:
No.of Devices or R uivalent
1111ach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value ofElectrical Work: (When required by municipal policy,)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion,
INSURANCE CO)ERAGR: 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 dertifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER [B (Specify:)�t�\�' ��1c•,L
I certify,.-under thepains andpenalties ofperjwy,that the it formation on this application is,&ue and complete: 1
PIRMNAMI;: ADT LLC DBA ADT Security
-� LIC.NO.: C-172
Licensee: Thomas J•. Lee %
Signure LIC.NO.: C-172
(Ifopplicable,enter "exemgt" 'n 117e license nu,n erline.) !. •_•_.
Address: \ c) Bus. Tel.No,
-- el\\off"I� U c�-k G� �
"Per M.G.L.c. 14t7,s.57-ol,secure wore re tyres 1� Alt• Tel.No..
g ant o public Safety"S"License: Lic,No. SS DO /779
OWNER'S INSURANCE 1ri�AIVkR; 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's agent,
Own er/Aent ,
Signature" Telephone No, _F PE.1.617T FEE:
I
CERTIFICATE OF LIABILITY INSURANCE DATE 10108/2014 IYYYY)
2014
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 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: _.
1560 Sawgrass Corporate Pkwy,Suite 300 PHONE
No Ext: FA/c No:
Sunrise,FL 33323 E-MAIL
Attn:FtLauderdale.Certs@marsh.com ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
048953-ADT-GAW-14-15 INSURER A:Zurich American Insurance Company 16535
INSURED American Zurich Insurance Company 40142
ADT LLC INSURER B: _
18 Clinton Drive INSURER C:
Hollis,NH 03049 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-003303542-01 REVISION NUMBER:2
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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR IN SR WVD POLICY NUMBER MM/DD/YYYY MMIDDIYYYY
A GENERAL LIABILITY GLO 5095899 02 10/01/2014 10/01/2015 EACH OCCURRENCE $ 2,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000
PREMISES Ea occurrence $
CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 2,000,000
GENERAL AGGREGATE $ 4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 4,000,000
X POLICY PE� LOC .__S—
B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000
Ea acc,d.rt S
X ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS AUTOS
NON OWNED PROPERTY DAMAGE S
HIRED AUTOS AUTOS Per accident
S
UMBRELLA LIAR LJ OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTIONS S
B WORKERS COMPENSATION WC 5095897 02(ADS) 10/01/2014 101/112015 X WC sTATu- oTH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 5095898 02 (MA,WI) 10/01/2014 10101I2015 2,000,000
OFFICER/MEMBER EXCLUDED? � N/A E.L.EACH ACCIDENT S
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 2,000,000
f yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 01845
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee �Launor �4.n tc.�a� e e
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD
�� ��epc��Prr�e�r��•f'If�a�l�s�`�°�r�l.�.ccic�e�a�,s i
u office ofTHvestigaptions
t Boston,KA .�.��3y /ptl1
�'�M SyVv`6 V VYV.IY ass.go P1 M_
Workers compensotion Insurance Affidavit. JI$�uu�a�errs/cC®Haan���®ns 4loctricians/FluRtnl��rc�
1p-]lapse,print LogjUl
a1718(Business/Orgauization/IndidiiQ1L �` -�
en
Address: _.CAt
` d n�E._ tiJl.,
`f Phone#: r€= 1 - i
city/Mate/Zip: 3
Are yourr an erg-r-ployer?Check tare approPriate box- Type of pr®jec'c(required):
1. "$ I am a employer wifh_�0 `. ❑ I am a general contractor and I 6, []New construction.
employees(full and/or pact-time).'` have hired the sub-contractors listed
C]Remodeling
listed on the attached sheet.'
2.❑ I am a sole proprietor or partner- These sub-contractors have S. ❑Demolition
ship and have no employees workers' comp.insurance, g• []Building addition
working for me in any capacity.
[No workers' comp.insurance 5• ❑ We are a corporation and its 10[]Electrical repairs or additions
required. officers have exercised their
right of exemption per MOL 11,[]Plumbing repairs or additions
3,ElI am a homeowner doing all work c•152 1(4),, 12•[]Roof repairs
myself. [No workers'comp. and we have no
insurance required,]i employees. [No workers
comp.insurance required.] Sat_a..Z k N-1
*Any applicant that checks box Of must also fill out the section below showing their workers'compensation policy information,
T H0IDe01Vner5 who submit this affidavit indicating they are doing all 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 their workers'comp.policy information,
cttn cart employer zeta is;�,oviding Wolters'cots efastatiort insrtrat?ce for f'r1'etszplayees. Belolp rs ilieolicy rtnctOb siie
;:�s�` SF �4.�'k:�:j€:ram `- �';�:-.,e•::_::r_�:_e ez t"„ "_'-�` _
Insurance Comp any Name
E� : ;, s ;3 ��.s = _ grx_ptaoiADatQ;
Policy#or Self ins.Lie.#: \ °�`-
^G'f_,� p cam- ( City/State/Zip;
xobSiteAddress: C �\�'�
Attach copy o the worizers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of i
fine up to$1,500.00 acid/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. Be advised that a copy of this statement may be forSvarded to the Office of
Investigations of the DIA for insurance coverage veci-�"ation.
1 do hereby certify trader the dvniru lan r�er'ialtie�f pex/trfy titcct tlae itaforr,Ia rovided above is t1we and correcr
Date•.co
}Si at wt
Phone#:
Official a e only. Do 110f Wite it'tells rtrerr,to be caapleted by city or town of Mal..
City or Town: Permit/f'Icense#
Issuing Authority(circle one):
J.hoard of:stealth 2.Building Depa$6:rxtent 3.Citylu owrr Clerk 4.Electrical inspectmx S,Plumbing Iurspector
6.Other
Contact:Person: Phone�: