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HomeMy WebLinkAboutElectric permit Date... ............... x TOWN OF NORTH ANDOVER PERMIT FOR WIRING 14U This certifies that CC-- ......................................................... has Permission to perform f ............. .......i............/........................................ wiring in the buildi 0 q X, Ai . ................. ........... at -,?— ............................................. 5"�.............;..........................................I North Andover,Mass. Fee —............Lic.NP/lez ................. .................................................................................... Check# 16t,;03 ELECTRICAL INSPECTOR u 6 7-J H4- f71 dac%iu6eltd _ O;iicial-UseOnly. • - — ''' L.alnYrwrzwea �.o, a6• • ' FOccupanc;3 No. • _ sl �par.try�,;;;F o��ire�ervicee BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked 71 (leave blank) t APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK g� � All work to be performed in accordance with the Massachusetts Electrical Code (PLEASE PRINT WINK OR TI'PE ALL WFORA TIOA) Date: (1v1EC), 5.. CMlt 12.00 City or Town of: `� � �� By this application the undersigned gives notice of his orher intentio o performTo the Ire electrical work described below. Location(Street&Number) Cj Owner or Tenant Q �'-- Telephone No•: + r Owner's Address - Is this permit in conjunction with a building permit? Yes •' ❑ No �(❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Am s r p / Volts Overhead ❑ Undgrd❑ No, of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity I g Location and Nature of Proposed Electrical Work: f Completion oLfthefiollowzng table ma be waived by the Inspector of wires. No.of Recessed Luminaires No.of Ce}l.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators ICVA No.of Luminaires Swimming PoolAbove ❑ In- ❑ o.o +mergency ignung �rnd. Qrnd. Battery Units No.of Receptacle Outlets No. of Oil Burners II{'IRE ALARMS No. of Zones No.of$witches No. of Gas Burners No. of Detection and No.of Ranges Total No.of Air Cond. Initiating Devices Tons INo. of Alerting Devices No.of Waste Disposers p Number Tons ICV4 No. of Self-Contained Heat Pump r Totals: _._. ....._._._.__....._._......._. __. _. Detection/A}ertin Devices No,of Dishwashers Space/Area Heating ICVit Municipal Local❑ ©Connection Ofhar No.of Dryers Heating Appliances r Security S•ystems:r No.of tilratcr No, of No.of Devices or E uivalent Si s Ballasts Heaters ICW No.as Data Wiring: amts No.of Devices or Eauivnlent No.H,ydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent g `�2 Estimated Value ofE]echical Work. /Itlach additional detail if desired,or as required by the Inspector of Wires. J Work to Start: (When required by municipal policy.) S Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C01'ERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the Iicensee provides proof of Iiability insurance including"completed operation"coverage or•its substantial equivalent. The undersigned dertifies that such coverage is in force,and has a ibited proofofsame to the permit issuing office. CHECK ONE: )NSURA.NCE El BOND ❑ OTHER (Specify:)St\j' 'n5C,!�Cxas� 1 certify-under the pains and penalties of perjurer,t/zat Me br formation on this application is z?iue and complete. 1 FIRMNAME: ADT LLC DBA ADT Security --�� LIC.NO.: C-172 ' Licensee: Thomas J. Lee g LIC.NO._ C-172 + - Si nature „_ I Wapplicable,enter "exempt" 'n the license num er line.) I Address: 1 C�.� U� Q +L- -i / t 13us.Tel.No. `- Alt.Tel.No.. (�-rig -6 "Ter M.G.L.c 147,s.57 61,security worn:requires[) nt of(�ubIic Safe -OWNER'S INSURANCE, WAIVER: .I am.aware that tl�i�e L�ieensee does not I are the liability insurarncevcoverage20 1779 f required by law. By my signature below,I herebyy Owner/Agent waive this requirement. I am the(check one)❑owner ❑ owner's agent. Signature Telephone No. _ PERMIT_FEE: 9)05, \) i • IIt v.. s io _gm :! is n T ::EI): 5Y{S;TEhI�::�.0 �� i ( r UR _ =AV' y \ t�. $6•' �r,ciiFe�_hVP-sY 1?1 r?'0 �•y• — ,..,..�--_---'_--.— is a Commonwealth of viassachusetts Department of Pubic Safety Security S}•steins-S-T.icenle i License:SS-001779 b homa5 j$tee j r.. 410 eve VT IN w s1 s Expiration' commissioner 051W2016 •I _ `r • i ( I The Comnionwealtli of Massachusetts Department of Iizrlusil ial Accidetzts i•ee 1 Conba l ess St t, uite 100 S _ ROYO rare!1_2.zr�_2n.7.7 www.mass.gov/dia ^� Worlters'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE,PERMITTING ALITHORITY. Applicant Information Please Print Legibly t 1 Name(Business/Organization/Individual): o t �� z Address: t� '�� i City/State/Zip: ® i� ���`� ���� `� Phone#: Are you an employer?Check the appropriate box: Type of project(required): I.[4,1 am a employer with CO employees(full and/or part-time).* 7. []New construction 2.❑lam a sole proprietor or partnership and have no employees working for mein 8. 0 Remodeling E any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[J 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.❑Roof repairs l These sub-con tractors have employees and have workers'comp.insurance.; 6.❑ officers We are a corporation and its ocers have exercised their 14.KOther L_a W 'J a right of exemption per MGL c. I 152,§1(4);and we have no employees.[No workers'comp.insurance required.] t E �C—t%�`�\ . S *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. p +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Beloiv is thepolicy andjob site Information. Insurance Company Name: Policy#or Self-ins.Lic.#: � S Expiration Dater Job Site Address:_ City/State/Zip:�o�'dd� � �(\jt); Attach a copy of the workers'compensa •on policy deelaration Page(showing the policy number and expiration date), k Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 of up to$250.00 a day against the violator.A copy of this statement mdy be forwarded to the Office of Investigations of the DIA for insurance t coverage verification. l+ I do hereby certify under the pains and penalties of perjury that the information provided above is irtre and correct. I Signature: Date Phone#: C.00 Fonly. Do not write itz this area,to be completed by city or fawn official.n: Permit/License#. hority(circle one): Health 2. Building Department 3.City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector [; son: Phone#: . t t DATE(MMIDDIYYYY) A CERTIFICATE OF LIABILITY INSURANCE 10106/2015 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 i 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 r certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME 1560 Sawgrass Corporate Pkwy,Suite 300 ATONE Exit: _ (aAic NPH o). Sunrise,FL 33323 E-MAIL f Attn:FtLauderdale.Certs@marsh.com ADDRESS: --- — -- _ INSURER(S)AFFORDING COVERAGE NAIC p 048953-ADT-GAW-15-16 INSURER A:ACE American Insurance Company 122667 INSURED INSURER B:Agri General Insurance Cornpany 142757 ADT LLC 18 Clinton Drive INSURER C:ACE Fire Underwriters Co 20702 Hollis,NH 03049 INSURER D: g INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003446293-04 REVISION NUMBER:4 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: ADD]SUER POLICY EFF POLICY EXP 1 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMMDNYYY MMIDDNYYY LIMITS c: A X COMMERCIAL GENERAL LIABILITY XSL G27400954 1010WC15 10101/2016 EACH OCCURRENCE $ 2,000,000 i UN RENTED—-- -- --- --- CLAIMS-MADE X OCCUR PREMISESTO Ea occurrence S _ 10W'000_ ( X SIR:$500,000 MED EXP(Any one person) $ PERSONAL 8ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,000 X POLICY L]JEST LJ LOG PRODUCTS-COMPIOPAGG 'S 4,C00,000 OTHER: $ A AUTOMOBILE LIABILITY ISA H08865073 10101015 110101016 COMBINED SINGLE LIMIT S 1,000,000 ;(Ea accidert) X ANY AUTO iBODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPFRTY DAMAGE: �. HIRED AUTOS _ AUTOS (Peraccident) S S i UMBRELLA LIAR _ OCCUR EACH OCCURRENCE S EXCESS LAB AGGREGATE 5 .CLAIMS-MADE o) x A IWORKERS DEMPLOYERCOMPENSATION N AT OTM - � 1 PER OTH y DED RETENTION$ N,'LR C48593318 UDC" 1n10L201` 0�0112016 T_ ER S ATUTF C oNT �F� e under I yes,�R yLMe�REXCLUDB ANY REXECUTiVE �N]LA �SCF a859'3311ti'lvl)) C,�L2015 10�0112016 �`EL DSFaSECDEEMPLOYEE S 2,000000 I DESCRIPTION OF OPERATIONS below F L.DISEASE-POLICY LIMIT S 2,000,C00 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if store space Is required) III Town of North Andover is Included as addil;onal insured(except workers'compensation):vhere required by written contract j I CERTIFICATE HOLDER CANCELLATION Town o(Ncrth Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:Electrical Inspects;, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 124?.lain St. ACCORDANCE WITH THE POLICY PROVISIONS. North,'%ndotier,VA 01845 AUTHORI/t-n f f PRESENTATIVE or M,rsn usn Ins MFl.rash•Muk^.eijee _T•;-c��.too•": ..,3�Q-.til�_n.,C.��-«.. c 1988-2014 ACORD CORPORATION. All rights reserved] x ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD II