Loading...
HomeMy WebLinkAboutInsurance Letter - Permits #12985 - 124 COTUIT STREET 12/15/2014 Date... fi ........ . ............... T#j TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 88ACHU A � Thiscertifies that ............................................ ........................................................................... �o has permission to perform --zv?-' ................................ .......... ..................I........................... wiring in the building J ..............................f...................................................................... LA� at .................................................... .......... .................... ..................North Andover,Mass.-, T,:ee.—i Lic. No. .......... . . ............. ........... ............ ..... .... .......... 'EE-CTRICAL INSPECTOR Check# Department al Flre Servfcea� Permit No.__ BOARD OF FIRE PREVC-Ni[ON REGULATIONS 99 �ea Checked rlease Occupancy and F Iz! -ldct -cares Ys�cajj [Rev.1/071 (k6ava blank) APPUCATION FOR PERM"IT TO PERFORM ELEGTRIC,,'AL WORK A wjectd -Twork fo be perfomad in nwx6nc.e. PEC), 527 CUR 12.00 (P LE4,"W PB-�AT I Vt )ATK OR TYPEALL zrfopn I-T4 yw)7w Cit A To the Inspector of TH),es. y oy Tayv-�ox,!� V-� By this applicawA the undersigned Is notice of hzs or-fterhatention to perform the electrical vi, -rk described below, Y--Ocaffo�x-('3freel"Fq- r4ztex or. ox ant A�.7 0-vmces AdJm,,g 19 ffif3,0exMiUR cox unetion tlz a D111103gPeMatt? M Yes (C-11eck Appropriate-Box) y2dsi-bug fez vice Amps I Volk Overhead El h1or"Ofudas; New S e ,Maps L-Voits owapaa EJ wgrd El -,,,o.anyxeters Xnwlbe�z ofFeediersaxtdkupacity -T-ccatloxz and Nature of)?xoposed Electrical 2e 7 l7sp V�ror.,k- I' -dorqf0-1 i , TO0Z Recessed L mkalreg of (Pa 0,Ot 'J"-OV.A ISboxmerg X ZvT NO.of Ho;:Abs 13111A of T-aininaire-g- &-F1Mm!ngP-oOl arxtd. mod, EJ laff Y, e D,its of Reeeptacle 01108ts [Na.of 4-iff Bimaen 111�''0-of zones X, No.of Switches IN04 of Gas No.o Deteclaorc and N.O.ofAir COO. Ions -No.of-Mle Urtgg Devices -No.Of V17astc-Dis-posers r Tans XVV 0.of,91--lif-Contained No.of Djullwashbrg IS*e/Axaa.11eatlag KW El n er No.of Dxy-us HeatingAppliquCes lay No. NO.Of NO.Off Heaters R'l Nyo,of Devices or Ectidva I lent N V o..Riydroma-sagn,'Rath-,ubs kqo-.of Nroforg TotaiMP Nu-of'DevIces ok� Livia Cent Aftach al 'd­'a ifiwyzrtd,-,,wf Vd8,rjre4 oravrequircdby z7iehupecioe of TIR,-eg. rstunatod Value Qxr-jectricalWark: 0 _ QV-hen required by municipal policy.) Work kto Start, S I'spections to be requested in accozdanca with AJEC.Ruje 10,and upon Compleij.0a. M&TO Mi&N,CF- bW e s 9 iMv e d by the e�;ner,ja o permit for tl-M P erfGaua-aca of aleatdcal work may isme imle,ss Abe licensee provides proof of liability insurance ineludj»g"mrap feted.op-arati oa*-'coverage or its substantial equivalent,.'the tedproofof.samB to the permit jsstqD.gq of:urc�. lmdars!"Med cexiffi,�-q f4at sircheoveragaisinforce and has c-�ffiibj' C-MCK ONE: RT.S*(a! At�Tcp, se-If-Disured 071 Ws aPPEIC1110AIs true andcom plete, M-M-NAAM ADMCDMADTS0ruix), Txc Mceasae: Thomas I Lee, sio arue;--2 -TI-TC.NO— C-172 licensa nizinheiv ZTC� 97appitrazle'.enle7.-Irwqp! fil Ait. X0, 7 C V Address: 172 To.No.. `geourlty System requirea-.LLor ijbis work;if applicable,cuter f he licew 0 3111mbel:he-ra: '0017,79, OVMOM)MMANCE WA)YER: I am awaza-that the,Li cans e o does not have the,liability insurance c overa go normally -requkedb3llaw. By my 9zpafiare belo-,�r,1hereby waive this requirement Qwmer/Age& AC:C)R"® DATE CERTIFICATE OF LIABILITY INSURANCE /YYYY) 10/08/2014I2014 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 AIONNo EXt- -__ is/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 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 SUER POLICY EFF POLICY EXP LTR IN SR I WVD I POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS 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 PREMASHL Ea occurrence $ CLAIMS-MADE n OCCUR MED EXP(Any one person) S 10,000 _ PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 7XPOLICY PRO- LOC -- $ - JECT B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accidert $ ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS ( ) HIRED AUTOS , N N-0VUNED PROPERTY DAMAGE $ ..___ _..1 AUTOS _Per acadent)_,—,.,, UMBRELLA LIAB OCCUR EACH OCCURRENCE S --- EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ j S B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 10/01/2015 X OR STMI1 OTH AND EMPLOYERS'LIABILITY TOY LIMITS A ANY PROPRIETORIPARTNERlEXECUTIVE Y/N WC 5095898 02 (MA,WI) 10/0112014 10101/2015 2,000,000 OFFICER/MEMBER EXCLUDED? � N/A E L EACH ACCIDENT S _ (Mandatory in NH) i E.L.DISEASE-EA EMPLOYEE S -2,000,000 If yes,describe under ------ --- -- --_-- ----- - (� DESCRIPTION OF OPERATIONS below ! EL DISEASE-POLICY LI NtITy 2,000.000 6 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 ��iatiinar v.Cc_r\�n -c e_ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Mossach vsefis Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Co mipensq I ractors/Eq Jectriciani s/Flumbexs Ai3plic�ant Information t&n insurance Affidavit: Builders/Cont Name(Bus iness/Orgaiiizationllndi-yidtiol)` 17S Address: r City/State/Zip: Phone Are you a eraployer?Check the appropriate box- Type of project(required): l.FA-1ama employer with_.N9,q 4. [1 1 am a general contractor and 1 6. El New construction_ employees(full and/or part-time)." have hired the sub-contractors 7. F1 Remodeling 211 1 ain a sole proprietor or partner- listed on the attached sheet. 8. E]Demolition ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. El We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 11.0 Plumbing repairs or additions 3.F1 I am a homeo-witer doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4),and we have no. 12.[:]Roof repairs insurance required.]f employees. [No workers' 13.El Other \4*J C_ comp.insurance.required.] SLc C-­, *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homemvriers vilic,submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check-this box must attached an additional sheet showirig the name of the sub-contractors and their workers'comp.policy information. faitianefnployei-tli.atispj,oviding workers'coitipeiisatio7tinsiiratice for iot)eitiploj;ees. Below.isthe.policy and1lob site information. 'Fit, t%. Insurance Company Name: �m- rvi a Policy#or Self-ins.Lic.4 5 Job Site Address: 0 City/State/Zip: OR— 0 � 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine i of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vcrit:­ation. -1 do hereby certify-under the palffs),7ndWnaldeesf-peijwy that the information provided above is true and correct Signature--fa Date: Vl_ 172�) VS- 11�CL(6 Phone#: Official rise only. Do not write in this area,to be completed by cloi or tots official Cite or Town: Perinit/License Issuing Authority(circle one): 4. Electrical Inspector 5.Plumbing Inspector 4.Board of Health 2.Building Department 3.City/Town Clerk 6.Other Contact Person: Phone#: