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HomeMy WebLinkAboutWiring permit - Permits #11934 - 28 BERKELEY ROAD 10/15/2013 i Date ....�`.' ` `�y e � ...... ................ µOH7►� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8'BACHtJ9f4 e� �cv � f Thus certifies that .... ..... �<y has permission to perform . � � � s .... :�.... � .r ........................... wiring in the building of ....................... at ?........ .9� �` .. .: .. ' ................ .North Andover,Miss. 3M N Fee... Lic No �,�� ..�" � ,�........BL cr.... P � INSECTOR 4a� � Check* E � . Gorn,1110MV00012 Of1 4c GIICd 2 5 Umqjt USP Vmy Dc-partmed of Fim BOARD OF FIRE PREVENTION REGULATIONS an cc IR?sq a zFp codes&-efeegric-laa"s cefl [��f,-v.1107] agghad ffi&bfd ppermfi;9 ff applicah q-ya blank) APPUCAVON FOR PERMIT TO PERFORM ELECTRICAL WORM All work to be pm.Lomed in rxudanc8 with the Massaduseffs,Elechiw Cod (W-C.),527 CmR. 12.00 (TEEASEPMEMMK OR TYTE�4ELWORWYZ04 Date-_ J(0/10 /1--3 To the:1wector of Wares: By thig appkaflon the=deH, 'yes c:a o f I u s or I.or mioatio P-to eT.LDrm ffiu de et�ca I waidc d e s ctffi FA b ol ow. ? Owner or Tom* (2 r-r-Cl (uj fs ffilq permit'la conjunction witit a building permit? YesE] 1116\kj (Cherk Appropriate Box) rnrpose of Building 'Utflity Auftr milon No. FAStiag HP-1--nee, Amps / Volt- OyerheadEl iindgrd-Fl- —No.ometers NBYV ser-vica Amps. / V,DlLq Overhead Fl. undgra El No.of meters --ffunx er of-YiEdars and �ic�!, Laoaffon and Natura of Proposed Ekl'MIC21 Work: CpmpfeHon qf&--_j'o1rbw[ng fablemay be wafvEd by the 1nspPcfqr of V;�e& of Total _ Twr No.of Lumin ake;0 utlefg INo.of Hot Tabs Generators �� Na,of Lmniaaireg Above El b- El sy�lmmiugpooj , Bane Units - —---------- Ida N6.of Switches Im Burners E' 'rs Of Detection.Aud TOW kT01 i of-Ranges No-of Air CmcL Tons No.of AlerflogDovices T of HeatPump Number I Tom IOW INo.of Self-Coutaincd No.o.of WastcD4osers 'Totals: Device-s No.of Dishwashers gpacOArea Heating XW Local Ej Municipal Con-aaction 0 offier No,of Dryers HeatingApplianceg ecurl Y No.of Devices or EquivaTL-nt No.of Water No.of JNO.of Data Wiring.- Heaters I S12S Ballasts No.of Devices or Eguivalent T�To.Hydro massage Rathtulg NO.of Motors TOW M? Telecominunicaflon,5 Wiring- Vb.ofNv1cesO)ZRqutiW0ni- O=R: EslimatedYguo 'BjctriDalWQZ,- 1645Z.OV (When raqairedby municipall policy.) 'Wovkto sbrk:r�z iu-TcDt[ons to boxc,,quastedia-accordauc4-,wiffLA4EC Rule 10,a3ad upon completion- INSI]TANCE COVERAGB: TTnTp s walyodby the owner,no pma'it for the P61formauco of elrctdcA work may issue unless tholimmm provides proof of liability insucmea including"completed operation"coverage or its substE-utlal cquivalen, The un&,--qfgnz-,d cer0es that such coverage is in force,and has eoffiibitpdproof of spro-D to the parmitissiling offm CHECK O--, INSURA-WCE 0 BOND F1 0=1 X. Solf hmed this Xcer*,,under thapaba ayidpe=X&�of perk-ry,Zha�]TIE th' 1�ae-(w d c ompldr- ppHcaLiva is ]�MMDTAW: ADT LLC DBA ADT Scuority LTC_No.: C-172 Licensee: Thomas 1.Lo LIC.1`t0-- C-172 ffqppac"619.P-.VfPr`2X-e)NVt'-1 51-69 1110�Se n1mhar Bus-Tel.NO., IK- A U 0 5- Addxess,- 0, e Alt TeLY Xo-:0-0 s ecu riiy Sysrem Coaft-acto r fic or,s D required 6 ibis w oric;if applicable, ft,x the license e uwa b or h bra., 001779 oWN- aware oR!sjNsU--L,)�CFWAjVBR. Im ' ara fhat&a Licensee does not'have the liabUity insurance coverage noYmally required bylaw. Bymysigoature below,1-herabywaivothis imp-iroramt Iamiho(check one)E]oymer El owner's agent. CY?ffier/Age-'at Sign.atura TeleokonelTo, NPAW - . The CommoniveizIth of Massachusetts Departm-etit i9f Industrial Accidents Office ofItivesiigttt oils r-'ref 600 I! avhingtntt Street n`= Boston,MA 02111 •�`��_���� tv�t€�.rttrtsti,�ulu/ilirt Workers' CompensafiDn Insuranee Affidavit. �ilA���sl�"�I�Irncft�rsfEl��t�������1latun�hc 1��; Applicant Information Please Print LcTibIy Name Security Services a]�'li}i .-A_:._., ;.�U�;IRi;tiSIC)f�3DP'LtYtSCill�lt1�t37t�tStttj— Y`' ------- Address:— 18 Clinton Drive __-- _-_-- --___ -- -- — City/S(ate/Zile:—__Hollis NH 03049 _---_ __ Phone Are you an enipio ev?Chccl<the appropriate boo 1),pe of project(required); 1.{ I an,a employer wait_1000+ 4. I am t+gt*mnit contractor and i New r otistrtietirin cttiployecs(t=tali and�or part-time)." have hired alai sub t ante actors 2.El i brat a sate proprietor or partrtcr- llste:d on the attached shut. 7, lfietiiodelinL ship and ha c no employees These tall-contractors have t1. ❑Derholition workin4 for nic in anyr capa its. r:•ttiployces arid have workers' _ comp,inst�rttljcc.t 9. � Building addition [No-,vorkxrs comp,insurance requirc,d] 5, Fj We aro a corporation and its 10,(]Electrical repairs or additions ?,El I am a hoillco4v711er doing all work offi-mrs.have:exercised their I Qj Phu-nbing repairs or additiotis myselE [No Nvorl<ers' comp. right of exemption pt:rMGL 12,E]RoofrupK'tirs insurance required.]T c, 152,§1(4),and 4ve have no e LOW Volta employees. [too workers' I I&I Other g _comp, insurance required.] SecuritV System Any applicant that vliecksbox irl vnwt also rill out the section below Showing;their)wrkers'conipcnsai ion policy information. fi Horneouvars who subil-tit this affidavit indicating they are doing ail work and theft hire oulsi4c contractors mint submit a itt;w affidavit vtdi€acing such tContractons that check this bax inust nuftuhcd an additional sheet shoving the nnnc of the sub-contractor,;and state whether or not those-entities have employc7cf, l(thesut>-contractors have cmplU)•eeS,lbey mu.it pto'iate their woA-ors'cc nip.policy number. f attt art emplcYer dart is prvVI(ittg workers'eontpensatintt insurtance for my e-Inployees•, Reloop is the policj,and jab site lttformarlon. hisurance Colrtpany Nt me, _._Zurich American Insurance Co. Policy#or Solt=ins,1.1c.ft; WC509589701/WC509589801 rxpiration Date: 10/01/2014 Job SiteAdtlri:ss' _ -, _ - - -{_ tY•' ip• Attach a copy of the workers'compensattots policy dcclal tion page(showing the policy number and expiration date). Failure to swwrc coverage as ra.'cluired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a line tap,to S I,z500,00 and/or one-year irtmprisonti cm; as well as civil penalties in the form of a.STOP WORK ORDER and a fine of tip to$250.00 as day ugainst the violator, lit}advised that a copy of this statement may be forwarder)to the Off co of investigations of the ILIA for insum,nee coverage vuriiicalion. I do herehy cert , under tltedxtits and penaltie?s of°pedirry f1l t the inform ath n proritic:d abuve is It'a and correct. 51911uture' / 4�`t- Date, Phone#.. 603-594-5937 _ Of ica'af rase vnly� Do tart nrite in this area,to he ctttty*fed k city or tr>wn taffieiaL City or I own: _ _ Pel itlll icense a Issuing Authority(circle cote): 1,hoard of i-leil.ltlt 2,Ruiltling Department 3.Cityx'clwn Clerk 4.Electrical Inspector 5.Plumbing.inspector h.Other - -Contact Person- Phone#: _ _ -i1 DATE(MM/DD/YYYY) A�vRO CERTIFICATE OF LIABILITY INSURANCE 09/25/2013 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 NAME: AOn Risk Services Northeast, Inc. Morristown NJ Office (A/C.No EXt): (866) 283-7122 FAAic.No.: (800) 363-0105 v 44 Whippany Road, Suite 220 E-MAIL p Morristown NJ 07960 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Zurich American Ins CO 16535 ADT LLC INSURER B: American Zurich Ins Co 40142 ADT Security Services 1501 Yamato Rd INSURER C: Boca Raton FL 33431-4408 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570051395419 REVISION NUMBER: 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. Limits shown are as requested INSR TYPE OF INSURANCE ADD SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MM/DD/YYYY .A GENERAL LIABILITY GLO 1 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1,OOO,OOO PREMISES Ea occurrence CLAIMS-MADE X❑OCCUR MED EXP(Any one person) $10,000 o-. PERSONAL B ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 PRODUCTS-COMP/OP AGG $4,000,000 c2 GEN'L AGGREGATE LIMIT APPLIES PER: � X POLICY PRO LOG o AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) Z ALL OWNED SCHEDULED BODILY INJURY(Per accident) N AUTOS AUTOS NON-OWNED PROPERTY DAMAGE M HIRED AUTOS AUTOS (Per accident) 'C N UMBRELLALIAB HOCCUR EACH OCCURRENCE L) EXCESS LIAB CLAIMS-MADE AGGREGATE DED I RETENTION B WORKERS COMPENSATION AND wc509589701 10/01/2013 10/01/2014 WC STATu- OTH- A EMPLOYERS'LIABILITY YIN wc509589801 10/01/2013 10/01/2014 X TORYLIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000_ _va DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) J� �y• at= �0 CERTIFICATE HOLDER CANCELLATION W SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE �w-- POLICY PROVISIONS. TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE INSPECTOR OF WIRES 124 MAIN ST. NORTH ANDOVER MA 01845 USA t�k7rfJ7E c%��GLaiGCDcJ7�try e./�YYGt ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD