HomeMy WebLinkAboutWiring Permit - Permits #12480-1 - 36 COLGATE DRIVE 7/15/2013 PPPP-
Date.... �.. . �. .................
�?�,•��'�, �.tioot TOWN OF NORTH ANDOVER
° PERMIT FOR WIRING
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Thiscertifies that ...........................................................................................................................
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has permission to perform .... �' 11 . ...�.. ..r.... ` .......................................
wiring in the building of .... �.......
orth Andover Mass.
at ......... ..... j >, ,N ,
Fee. . ..............Lic.No. ..... .. f.. .: ...° !'{....6N ,r :. ......................
ELECTRICAL INSPECTOR
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Colnt"nweafik 017f a66acliWeff6'
Only
Permit No:,
2epa"'Im--rd 0/' ire Seiviced 79 Occupancy and Fee Checked
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BOARD OF FIRE PREVENTION REGULATIONS [,:
IRCA'* 1/071 .cave blank)
APPLICATI"ON4 FOR PERMIT TO PERFORM ELECTRICAL WORK
All woric to be,performed in accordance with the Massachusetts Electrical Code(MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORAdA TJOA9 -Date: 7 6
City or Town of: , -)dwe r
J—LW 6 l i To the Inspector of F[IiJ°es:
By this application the undersigned gives notice of his or her iii.,:D(p t -form tile electrical work described below,
an to
Location (Street&Number) t' n to pet
Owner or Tenant Telephone No
Owner's Address
Is this permit in conjunction with-a building permit?
Purpose of Building Yes ❑ No El (Chaelc Appropriate Box)
Existing Service AmpsUtility Authorization No.
Volts Overhead ❑ Undgrd n No. of Meters
New Service Amps Volts Overhead El Undgrd 0 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of thefiollowinz table may be ivaived by the b7spector 0 .'es,
No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No, of Total
Transformers KVA
No.of Luminaire Outlets
No, of Hot Tubs Generators KVA
Above-nd. ❑
gBaneNo, emergency gfiring
No.of Luminaires Swimming PoolEJ Bane , nits
No. of Receptacle outlets No, of Oil Burners FIRE ALARMS INo, of Zones
No.of Switches No. of Gas Burners No. o Eection and
No.of Ranges No. Initlatin2 Devices
No. of Air Cond. Tons jNo. of Alerting Devices
No.of Waste Disposers heat PurnpF_ on j ISelf-Contained
Totals:I .......... ....... 1;6 1, 1��: i
IDetection/Alerting Devices
No.of Dishwashers Space/Area Heating ICM1 Municipal
Local R Muni ' I Ofhp.r
No.of Dryers Heating Appliances "I OUL;UrRy Systems:-
NO.of'"later No - .v a f en"t
Heaters o, of No. of 7,1
Data Wiring:
Signs Ballasts No of Devices or Eauivalent
No.Hydrom2ssage Bathtubs No. of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or Equivalent
attach additional detail ifdesh-ed,at-as required by the Inspector 91il-es.
Estimated Value of Electrical Work:
(When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NEC Rule 10, and Upon completion,
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed Operation"coverage or its substantial equivalent. Tile
undersigned dertifieg that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CI_MC1C ONE: INSURANCE D BOND n OTHER U- ' (Specify:) -4;*e-\� k t1Sc4Qltz-s�
I certify,--under the pains and penalties of
that the i7forniafion on this application is,tiwe and complete:*FIRMNAIVIEl: ADT LLC DPA ADT Security
LIC.NO.: C-172
Licensee: Thomas j. Lee Sign-,f6re
(If applicableenter
Xemyt the license nuinq I LIC.NO.: C-_172
le
Bus. Tel.No
Address: to '0' F 0 . 1 J0
'Ter M.G.L,c.. 14A security wore:requires Alt.Tel.No.. . . 3 , 1Z
.OWNER'S INSURANCE, )YAIVER; I arn.awarices bq.&t(ment ofPublic,'3af6 "S"License: Lic,No. S-S 00 177
that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, hereby wave this requirement. I am the(check one)
Owner/Agent 1hb i ❑owner 0 owner's agent.
Signature' Telephone No, PE-R-MYT FE.E: --DL,
,Y
u 0J-jee of.1nves°iigelfeons
d 600 l��shif g for',�`l1°eel
t �os�oxa,1 M 02111
oqM Sy�v9 Vwlv,mass govIdity
ranceAffidav>Zt BnilderdeondnaEto>rg 4 j �I b
.A l(n��lat�r�fo>l ration
NaM(Business/Oxgauization/Indlyid-it8iL,_ i
Address:- Phone
City/,Male/Z�p-- --
t Type of project(required):
Are yore an egrnployer?Cheek the appropriate hox:
' 4, ❑ 1 am.a general contractor and i 6. NOWconstruction-
1,MI am a employer with_���?. - have hired the sub-contractors
employees(full and/or paIt time).` listed it attached sheet.' 7' ❑Remodeling
2.❑ S am,a sole proprietor or partner- These sub-contractors have &. ❑Demolition
ship and have no employees workers'comp.insurance. 9, []Building addition
working for me in any capacity.
[No workers' comp.insurance 5. ❑ We are a coif n ratio and its 10 Electrical repairs or additions
required.] officers have exercised their
Q
right of exemption per MCJL 11.Q Plumbing repairs or additions
3, 1 am.a homeowner doing all work
myself. No workers'comp. c.152, §1(4),and we have no 12.[]Roof repairs
insurance required,]7 employees.Wo workers 1; •prier 1 cnr;�
comp.insurance required.] Si e '��� 5` S
"Any applicant that checks boil must also fill out the,section below sliowing their workers'compensation policy infonnation,
doin�x all Homeowners who submit this n�dE attached indicating
additional slt et howi ig ba are oftl e and then hire usuU coutracfo s and their workerstside contractors must submit 'o p-polieydinforngfi n.
}Contractors that check this box
all,att errployer slim`is providing workers'CoraVerasatiorz insurance f or my erf'Tloyees: Belolp is the policy andlob site
information.
IV.-
:i:" R$ ]%Y 6[f •,_..Ca` ':�._o:�ai`. 4:r v_cr= 'irtir.et:s'�2'�
X any Nama:
nsurance Comp
,V Lp?-{'t3j>-,o'tll.�u
:Policy 4 or Self-ins,Lie.�: '�:.�rl , ��`'3 :"'' .;� ; :`t .
� �� i City/State/Zip:
Yob Site Address: f '
Attach a copy of rho worlrers'cornpensation policy declaration page(showing the policy nFrrnber asrd expiration date).
minal penalties of a
Failure to secure coverage as required under Section 25vA oell aMGv 1 penalties inethe form of a STOP WO_ad to tho imPosit!011 of IRK ORDER and Cne
fine,up to$1,500.00 and/or one imprisonment,
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 verl-:,,,ation.
ClO IZP,re6y CettlSy'rf, � tIledvar`rz��� `De— — P?�Ri .(e1jiliy that tfie ir2fbYYr2(f€.tora.7i'ovidea'abboovve is irtle and co-rPeee
// Date
Signatures ,G�L6z
Phone M LC'�.�-j�Jy 513 7 —
0ffrcial rFse•only. err not tprite in dais area,to be eorrpleted by City or town oJJ fe€al
city or Tomm: A ermifll,icense
Issuing Authority(cirdO one):
:E.hoard of l ealtlr 2.Building Depar a:zgzeitt 3.Ci dawn Clerk 4.Electrical Irlspector ,Plumbing iu§pcetor
6.Other
FP one ff° _
Contact,person-
,ac R CERTIFICATE OF LIABILITY INSURANCE DATE/2014 /YYYY)
1o/osl2ola
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
1560 Sawgrass Corporate Pkwy,Suite 300 (A/C,No.Ext):
Sunrise,FL 33323 ADDRESS:
Attn:FtLauderdale.Certs@marsh.com
INSURERS AFFORDING COVERAGE
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 IN R WVD POLICY NUMBER MM/DD/YYYY MMIDDIYYYY LIMITS
A GENERAL LIABILITY GLO 5095899 02 10101/2014 10/01/2015 EACH OCCURRENCE ___ $ 2,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000
PREMISES Ea occurrence $
CLAIMS-MADE LXI OCCUR MED EXP(Any one person) $ 10.000
_ PERSONAL BADV INJURY $ 2,06070 00
GENERAL AGGREGATE $ 4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000
X POLICY PE OT- LOC $
BINED SINGLE LIMIT
B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COM d ert $ 1,000,000
Ea acci
IXI—
ANYAUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Pidt
__ AUTOS AUTOS ( er accident) $
HIRED AUTOS NON-0WNED PROPERTY DAMAGE $
— AUTOS Pe,acddent
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $ _
DED I I RETENTION$ $
B WORKERS COMPENSATION WC 5095897 02(AIDS) 10/01/2014 10/01/2015 X vuC STATu- OTH-
AND EMPLOYERS'LIABILITY TORY LIMITS_. ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 5095898 02 (M A,WI) 10/0112014 10/01/2015 2,000,000
� $
OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT
(Mandatory in NH) E.L.DISEASE-EA_E_M_PLOYS $ 2,000,000
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
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
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 _SM.rxuorat Cc_�i c e_
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD