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HomeMy WebLinkAboutWiring Permit - Permits #13128 - 34 BALDWIN STREET 3/2/2015 Date...—.......... ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU rA This certifies that ..... ................................................................... .................................. .. 4 has permission to perform ............. ......................................................................................... wiring in the building of....... ............ ................*......**.......... tJ ....................................... at .............:.......................... North Andover,Mass. Fee.. . ............Lic.No. .... ..... ........1.)....... ............. ................. EL!tdRICALINgPECT6R Check# COMMonweaGth Of/6a.machuieff?` O ciai"Use Only cc•�� r [[Rei rmitNa, )� ,.g - o.Uetoartm.ent o��ire�ervicee __ BOARD OF FIRE PREVENTION REGULATIONScE] cupancy and Fee Checked 1/071 (leave blank) APP LIGATION FOP, PERMIT TO PERFORM ELECTRICAL WORK a All work to be performed in accordance with the Massachusetts Electrical Code(tv1EC), 527 CMR 12,00 (PLEASE PRINT W NK OR TYPE ALL INF01A1L4T10119 Date: City or Twn By this application the undeorsrgned rvPs notice of his r he c" Q.. 1"� To the Il7SPeetol' Of TTlipes, r intention to perform the electrical work described below. Location (Street&Number) "X Owner or Tenant -'gy 77­ Owner's Address m... Telephone No: Is this permit in conjunction with a building permit? fires . ❑ No �❑ (Check Appraprinte Box) Purpose of Building Utility Authorization No, Existing Service Amps / 'Volts Overhead ❑ rd Und 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 Woric; Com letion of the followin table ma be a aired by the inspector of Tfires. No. of Recessed Luminaires No,of Ceil.-Susp.(Paddle)Fans No. of Total Transformers ICVA No.of Luminaire Outlets No, of Hot Tubs Generators XVA No.of Luminaires Swimming Poo] Above ❑ In- ❑ o. o +mergency rgnrzng �rnd, arnd, Batte 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 Cord. `total Tons No. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons o. of Self-Contained Totals: ..... . .. . ........................................................... • Detection/Alertin Devices No.of Dishwashers Space/Area Heating I��r Local❑ Municipal Connection Qfhar No.of Dryers Heating Appliances gar Security Systems", No.of Water No.of Devices or E len —va 't No, of Heaters KW No.of Data Wiring: Signs Ballasts No.of Devices or Bauivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER; No.of Devices or E uivalent 1I11ach additional detail ifdesired,or as required by the Inspector of t11ires. Work to Start: !Work: j Estimated Value of Electric _ `� (When required by municipal policy.) '` Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit fo'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 dertifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER Mf (Specify:) Se-X ' i(1Sr � Icertify,.under the pains and penalties ofperjury,that the itzforniation on this application true and complete: FIRMNAME: ADT LLC DBA ADT Security Licensee: Thomas J. LIC.NO.: C-172 , Lee j ' Signure �� c-- LIC.NO.: C-172 (If applicable,enter "exempt" 'n the license num er line.) ,(_•_•_, / c_ Address: C3 v C<�o R C . `'. - t U ., q .)Bus. Tel.No. �{_ � �-I Alt.Tel.No.. t � '"Per A .G.L.c, 14'a,S.57-61,security worr<requires 1.1 a,��,ent of:(ublic Safe .OWNER'S INSURANCE WAIVER: I am.aware that ttthe,Licensee does not have e the liability insurance lcoverage norm ally required by law. By my signature below,I hereby waive this requirement, lam the(clieck one) ❑owner _ ❑ owner �aqipt, SignatureTelephone No, PERMIT FB'E: $,� i I i QC © CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/08/2014 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: PHONE FAX 1560 Sawgrass Corporate PiSuite 300 _IAIC.No.Ext1 A/C No): ___,___ Sunrise,FL 33323 E-MAIL Attn:FtLauderdale.Cerls@marsh.com ADDRESS: 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. —.. NSR I LTR TYPE OF INSURANCE INSR M SUER POLICY EFF POLICY EXP LIMITS LTR SR WVD POLICY NUMBER M/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY GILD 5095899 02 10/01/2014 10/01/2015 EACH OCCURRENCE S 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000 —...._...._._ PREMISES Ea occurrence _J CLAIMS-MADE M OCCUR MED EXP(Any one person) S 10,000 _PERSONAL&ADV INJURY S 2,000,000 GENERAL AGGREGATE S 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 4,000,000 X POLICY J ROT- LOC S B AUTOMOBILE LIABILITY IBAP 5095900 02 10/01/2014 '10/01/2015 COMBINED SINGLE LIMIT 1,000,000 LEa cc a ,dent) _ $ X —._.__...._._ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED (Per accident) BODILY INJURY Pident S AUTOS _ AUTOS ( ) NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS (Pe_raccidenti I I UMBRELLA LIAB OCCUR f ( EACH OCCURRENCE EXCESS LIAR 1._CLAIMS-MADE' AGGREGATE S -- DED I !RETENTIONS S B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 1010112111 X WC STATU- J OTH-� AND EMPLOYERS'LIABILITY __TORY LIMITS 1 --ER_ __ A ANY PROPRIEroRIPARTNER/EXEcurlvE Y/N WC 5095898 02 (MA,WI) 10I0112014 10/01/2015 2.000,000 DESCRIPTION OF OPERATIONS below �F.­.EACH ACCIDENT (Mandaory in NH)EXCLUD NIAL.DISEASE EA EMPLOYEE S 2,000,000 If yes,describe under ---- ------ -- EL.DISEASE-POLICY LIMIT S 2,00Q000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 ATTI: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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD _CX The Comrnonweadth of 13dassachusefis Department of Industrial Accidents Office of Investigations b 600 Washington Street Boston,MA 02111 www.mass.gov1dia . �riciani s/Plumbers Worl(ers, Corapelosation Nsurance Affida-vit erg/Contractors/Eleef I?Rease Frint Legjb_=1_Y AmAlca'ut Inforalpflon Name(Business/Orgaiiizatioii/IndjyicLi EL Address: City/State,/Zip: tl 'Phoneg: Are your an employer?Check the appropriate box: Type of project(required): I.F&Iama'ernployerwith \(j(jo± . 4. F1 I am,a general contractor and 1 6, F1 Now construction. niployees full and/or part-time have hired the sub-contractors 7. [] Remodeling 2.Ue listed on the attached sheet.1 I ain.a sole proprietor or partner- These sub-contractors have 8. F1 Demolition ship and have no employees working for me in any capacity. workers' comp.insurance, 9, Building addition [No workers' comp.insurance 5, F1 We are a corporation and its 10.❑Electricair'epairs or additions officers have exercised their required.] right of exemption per MOL 11.F1 Plumbing repairs or additions 3,F1 I am a homeowner doing all work c. 152, §1(4),and we have no 12.F]Roof repairs myself. Wo workers' comp. employees. [No workers' H. \1 0 insurance required.]t en1p F1 other 1� comp.insurance.required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation, tiTolneoNv tiers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tc,ontractors that check this box must attached an additional slieetsliowiiig the name oftliesub-contractors and their workers'comp.policy information. I arn an employer that is providing workers,compensation insurance for rf-W enTloyees. Below is the.policy and job site information. rM 6EXV41,111-.��-.­�J n. Insurance Company Name: .4 ,. -- -, , 9)'�,40, "S Policy ff or Self-ins.Lic.#: _p Do ta Job Site Address: City/Statc/Zip: Attach a copy of the workers' compensation Policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 aiidlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Office the of lip to$250.00 a day,against the violator. Be advised that a copy of this statement inay be forwarded f-o fee of Investigations of the DIA for insurance coverage veri�­ation. 1'(Ioliet-ebycertify-tiiider the paiiis,!-n e/z qfteyjury that the 111fornnation provided above is true and conwee Signature� Date: Phone#: Qfjlclal use only. Do not Write N this area,to be corrapleted by city or town offlelal City or Town: Perruit/License 9 Issuing Authority(circle one): Cler 4.Electrical Inspector 5.Plumbing Inspector 4.Board of Health 1 Building Department 3. City/Town k 6.Other Contact Person: Phone#: