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Home My WebLink AboutWiring Permit - Permits #13162 - 34 BALDWIN STREET 3/17/2015 4� l 7`� Date...... �. ................. 04 hoar",."tio TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING ,88ACHU5f� ..k.. .................. " This certifies that .e: ........... ., g ..... ......... has permission to perform .. ......... t i .............•....... wiring in the building of..... '•• ,.. r,Ma ss. NorhAndove ... at C . Lic.No: ........ Fee........... ELECTRICAL INSPECTOR Check# H \ _. C o�nmorowerzGcz�.o � - --- � /i r///�a6vachGtdng? � � ' Offici I Use Only -- rryy l S Permit No. _ a.Jeparlrn�nf o ire ervicee ' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rey l/07] (leave blank) APPLICATION FOP PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CMR 12.p0 (PLEASE PRINT INNK OR TYPE ALL NFOIU164TJOA9 'Date: Cite or Town of: t - . k, : W To the.Inspector of TT1jpes, By this application the jg ives notice of his o.her i lnt form the electrical work described below, ." Location(Street&Number) ned g f intention to per W i Owner or-Tenant Telephone No: �" 6 •' , w, p 7 .� 1 Owner's Address —6 �� Is this permit in conjunction with a building permit? Yes El No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No, of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work , Completion of the followin table may be waived by the IiTspector.of Wires. No,of Recessed Luminaires No,of Ceil.-Susp.(Paddle)Pans No' of Total j~ Transformers KVA ! No.of Luminaire Outlets No. of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ .In_ o,o emergency rgnrrng y ernd. prod, ❑ Batter 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 anges No. of Air Cond. Total No.of R Tons INo. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ICW No. of Self-Contained Totals: .....•.................•.......... ..................•...................... Detection/Alertin Devices No. of Dishwashers Space/Area Heating I �Ar Local❑ Municipal Qfhar Connection No.of Dryers Heating Appliances IOW Security Systems-* No.of Water o' No.of Devices or E u No, i ivaI zit �y Heaters KW No,of Data Wiring: Si ns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP I elecommunications Wiring: No.of Devices or E uivalent OTHER: . Estimated Value of Electrical Work: , ilttach additional detail if desired,ar•as required by the Inspector of Tflires. (When required by municipal policy.) Work to Start:_ - /'�[ 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 Iicensee 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 &-LI (Specify:) ` nVvt Q'::A I certify,.iinder the pains andpenalties of perjury,that the irzforntation on this applicatio�,t zie and complete: I FIRMNAME: ADT LLC DBA ADT Security I LIC.NO.: Licensee: Thomas j. Lee C-172 (Ifapplicab Signure _�� — LIC.NO.: C-172 le,enter "exemtlt" 'n the liceyrse nwnDer lirreJ l_•_._• / i_ Address: Tel.No, t� tti }`-{ *Per M.G. Alt.Tel.No.. l � L.c. 14'a,s.57-G1,securit} wori<requires 1� a ~�'� OWNER' INSURANCE 1�rAIVIs'R: I am.aware that�th�e Licei�e does»ot 1 arse the liability Lic.insurancecoverage--normally required by law. gy my signature below,I hereby waive this requirement. I am the(check one) ❑o��riier_ Owner/Agent ❑ owner's agent, Signature Telephone No, PERIIIIT FEE: ' The Commonwecdllt Of TMIsst-cliusetts Department of Industrial Accidents office of Investigedions 600 Washington Stmet Boston,MA 02111 wjvw.mass.go-vl dia WorIcer,9' Cornipensotion Insurance Affldavit, Builders/Contractors/.Electricians/plumbers A icant Inform Name(Business/OrganizatioDJfndjyicLiiol)-% Address: u_ D > City/State/Zip: ��o Phone Are you an employer? Check the appropriate box: Type of project(required): 1.[A-I am a*einploycr with \00o;� 4. rl I am a general contractor and 1 6, ❑New construction. ern have hired the sub-contractors to (full and/or part-time). listed on the attached sheet. 7. ❑Remodeling I am a sole proprietor or partner- These sub-contractors have S. ❑Demolition ship and have no employees workers' comp.insurance. 9, Building addition working for me in any capacity. S. F1 We are a corporation and its [No workers' comp.insurance 10.❑Electrical repairs epairs or additions r quired.] officers have exercised their e right of exemption per MOL II.F]Plumbing repairs or additions 3111 am a homeowner doing all work c.152, §1(4),and we have no Un Roof repairs myself. [No workers'comp. [go workers'ees employ . insurance required.]f 13.ZlOther comp.insurance.required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy inforniation, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Cdntractors that chock this box must attached an additional sheet showiiig the name ofthe sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'con?pensation insuraneefor rrV employees. Below is the.policy andjob site informadon. Insurance Company Name Policy#or Self ins.Lie. 9 la! .Dtp, L5 N, c Job Site Address: City/State./Zip. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a 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. Ba'advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance,coverage veril:ation- 27- d abo Pe is true and correct I t(o It e i-e by c Wify-un der,h ep ains,) nd,'p e 11.a.Wes"of�eyju ry th Ut the inform a do n p i ovide Date' - by city or town oflicial City or Town: Permit/License Issuing Authority(circle one): own Clerk 4.Electrical Inspector 5.plumbing Inspector .1.Board of Health 2.Building Department 3. City/T 6.Other Contact Person Phone#: A4C"R" CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY) 10/08/2014/2014 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 AHONNo,Ext): I(A/C No): Sunrise,FL 33323 ADDRESS: Attn:FtLauderdale.Certs@marsh.com ---- — — INSURER(S)AFFORDING COVERAGE NAIC# 048953-ADT-GAW-14-15 INSURER A,Zurich American Insurance Company 16535 INSURED INSURER B:American Zurich Insurance Company 40142 ADT LLC 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 LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY GLO509589902 10/01/2014 10/01/2015 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000 _ PREMISES(_Ea_occurrence S CLAIMS-MADE F�OCCUR MED EX_P(Any one person) S 10,000 PERSONAL&ADV INJURY S 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 4,000,000 X POLICY PRO LOC $ JECT B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accidert)__ X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS ( )_ NON-0WNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peracadent S UMBRELLA LIAR OCCUR EACH OCCURRENCE !S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS ! S B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 110/01/2015 X WC STATU- OTH AND EMPLOYERS'LIABILITY _TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 5095898 02 (MA,WI) 1010112014 10/01/2015 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 If yes,describe under ! __----_- DESCRIPTION OF OPERATIONS below j E L DISEASE-POLICY LIMIT S 2,000,000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 0 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 _31�tLlV_Ppthi @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD