HomeMy WebLinkAboutWiring Permit - Permits #12521-1 - 36 COLGATE DRIVE 7/22/2015 Date .... �
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ...... :VNTI ` . ............................................................
has permission to perform . ..... .....11k2.. ... -
wiring in the building of.....:.:: . ..�`� ............................... ..................................
� d at � ,..... , „� ,L .ue ,Forth Andover,Mass.
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Fee-!".., - Lic. No � f ' v ,°'�
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ELECTRICAL INSPECTOR
Check# s
�� ommonweaGcii.O/j/Ylaeeac411et(` ' Official-Use Only
' Permit Nc, " w. ��.....
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BOARD OF FIRE PREVENTION REGUL Occupancy and Pee Checked
REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION[ FOP, PERMIT TO PERFORM ELECTRICAL WORK
All work to be,performed in accordance with the Massachusetts Electrical Code(IvfEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE AXL INF0RhI.,4T'ION9 Date:
By this application the undersigned intention
Ci or Town of: �� To the hzspectol• of T(,1ipes;
)g d gtvPs notice perform the electrical work described below,
( of his or her to
Location Street cC Number74
eo
. w
Owner or Tenant
Telephone No: o G "
Owner's Address w
Is this permit in conjunction with a building permit? Yes
❑ No �(❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
.Existing Service Amps / Volts Overhead ❑ rd Und
g ❑ No, of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No, of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed,Electrical Work:
Coin letion of the followin table may be waived by the Inspector of g i?.es.
No. of Recessed Luminaires No,of Ceil.-Susp,(Paddle)fans No. of Total
Transformers IVA
No.of Luminaire Outlets No, of Hot Tubs Generafars KVA
No. of Luminaires SwimmingPoo} Above ❑ In- ❑ o, o emergency tgnnng
ernd. arnd, Bane Units
No.of Receptacle Outlets No, of Oil Burners (TIRE,ALARMS No, of Zones
No.of Switches No, of Gas Burners No. of—Detection and -
Initiating itiating Devices
No.of Ranges No. of Air Cond. Tons �No. of Alerting Devices
No.of Waste Disposers Heat Pump Num}�er Tons ICP4' No. of Self-Contained
Totals: ......... ................................................................
Detection/Alerting Devices
No.of Dishwashers Space/Area Heating IOW Local O
Municipal
❑ Connection fhpr.
No.of Dryers Heating Appliances K101 Security Systems:''
No.of Water No.of Devices or E uivalenf
Heaters IOW No of'°t No. of Data Wiring:
Signs Ballasts No.of Devices or Eauivalent
No.Hydro massage Bathtubs No, of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices ot•Equivalent
Estimated Value ofElech•ioaI Work
I;
IItlach additional detail if desired,or as required by the b7spector of Tf"ires.
Work to Start: Sps ed t (When required by municipal policy,)
�
p o be requested in accordance with W-C 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 [ (Specify:) '` '
I certify,.under the pains and penalties of perjutY,that the bzfbrniation on this applicatio�,tjwe and complete.,1
FIRM NAME: ADT LLC DBA ADT Securit y
"•- LI
Licensee: Thomas j. Lee C.NO.: C-172
j
Signure ❑❑ -� — LIC.NO.: C-172
(IJapplicable,enter "exemgl" 'n the license naun er line.) ._._. / `` � Q t_
Address: ��(RUC\ �C, I 'Ye`{ I I3us. Tel.No. d
Alt.Tel.No.. .`''Per M.G,L,c. 147,s.S J-61,security warK requires DCV&Oment of'(�ublic Safety"S"License: Lic,No. 5 s UU 17�7
.OWNER'S INSURANCES WAIVER: I am-aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner Owner/Agent El owner's agent,
S;gtzature Telephone No, _ PEZ�MYT FEE: �'_�,, tom.
1
CERTIFICATE OF LIABILITY INSURANCE DATE t01O8/2014 /YYYY)
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 A/CNE.No Ext: a/c No
Sunrise,FL 33323 E-MAIL
Attn:FtLauderdale.Certs@marsh.com ADDRESS:
INSURERS 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 INSURERD:
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.
INSRLTR TYPE OF INSURANCE INSR POLICY POLICY NUMBER MMIDD/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
PREMISES Ea occurrence $
CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,000
_ PERSONAL&ADV INJURY S 2,000,000
GENERAL AGGREGATE $ 4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 4,000,000
X POLICY FE OT- LOC $
B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000
Ea accident $ _
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Per accident $
AUTOS AUTOS ( _) _
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED I I RETENTION$ $
B WORKERS COMPENSATION WC 5095897 02(AOS) 10/01/2014 10/01/2015 X WC STATU- OTH-
AND EMPLOYERS'LIABILITY _.........TORY LIMITS ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC 5095898 02 (MA,WI) 10/01/2014 .10/0112015 2,000,000
0FFICER/MEMBER EXCLUDED? N NIA E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE _$ 2,000,000
f yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/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
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.
i Manashi Mukherjee _1�t_arunv�ti Td.�t�r�uc c-
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
DePaTiftlen't Of JUZUWJJ�bug
ojjn'ce ofInvesligallOns
600 ffl�shlllgffin ffijre-ol
Bo3ton,PIA 02111
-m)1q)Iv.masY.g0V1WhI-
Workeral corp-pona'Mrion Nsurance Affida0f:
so, Prin's LeglLb_V
Ap
Nalaf 0(Businessioxganization/Ind
tul V�7
Address:
-31 I
-1
Milo E
City/Staic)/Zip- 'VIO
Are YOU all OUR-Ployer?ChecIc tile appropriate bT,-
Type of project(required):
"
\(3 0()"-. 4. 1 am a general contractor and 1 6, U NOW construction.
1.[AI am a'employer with have hired the sub-contractors 7. r]Remodeling
employees(f sheet.1
2.F (.full and/or pact-time).'' listed on the attached 8. rl Demolition
I am a solo proprietor Or partner- These sub-contractors have
ship and have no employees workers" comp.insurance. 9. Building addition
Working for ma in any capacity. F corporation and its BIC , additions
[No workers, comp,insurance 5• J We are a coi 10. efrical repairs or
required.] officers have exercised their Plunibing repairs or additions
right of exemption per MGL 11
•3 1 am a homeowner doing all work c.152,§1(4),and we have 110 12.❑Roof repairs
myself [No workers comp. employees.[No workers'
Other ���_�YE
insurance required.]f comp.insurarice.required.] ��t (�
I SA_
*Any applicant that cheeks box fl must also fill out the section below showing their workers'compensation policy infonnation,
doijf,v,,r all,,yoik and then hire outside ooatraefors mot workers'
affidavit indicating such.
i-forticowners;who submit this affidavit indicating they are - s'comp,policyiDfoiniation.
al sliect shwll�g the name ofthe sub-contractois and their worke,
�Contractors that check-this box must attached an additio
informadoll.
3 4.1
IV,
Insurance Company Name:
Policy#or Self ins,Lic.
tate/Zip:
lob Site Address olicsr declaration peg®(showing the policy.-aumber and expirMIOIA&W-
Attach 2 copY 0 0 the imposition of criminal poiialties of a
Failure,to secure Section form of a STOP WORK ORDER and a fine
fine up to$1,500.00 aixdlbr one-yearimprisonment: ent may be fon-Varded. to the Office of
of up to$250.00 a day,against the violator. Be advise that a copy of this stateni
Investigations of the DfA for insurance co
verage ved —allori.
7 IjIfly ffiat Mie inforrriationflpovided above is trtle and con,ect
yeby aye
Date-
c1f,y or lawn o#Waf
City or Town:—————
Issuing Authority(ci[WIO 011c): ni 3.CityrA own Cierk 4.Electrfcd Inspector 5-plurub'ng fuspector
4.Board of Bealth 2.Building Depart e
6.Oth or
phone 3V:
Contact Person.