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HomeMy WebLinkAboutWiring Permit - Permits #11913 - 58 COBBLESTONE CIRCLE 10/8/2013 i Date p`ORT/.4, o�a;'':'.;';�•�ao TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �$ACHUS(� This certifies that I has permission to perform �� .. ..................' wiring in the building of....... ;a`' ` pp � 1 r P at ........: ....... ......... .... ... ..: .. North Andover,Mass. P Fee...... .............Lic.No. .............. �.. .... .' .. �.........,. ELECTRICAL INSPECTOR Check# omcial Use only Gornrtlonwealtb ofNassaoftclse€s I` Depadment o im Ser-tflc'as PeamitNo, BOARD OF FIRE PREVENTION REGULATIONS ama ease a ;du codes&electrician's cell ° ee nec_ ! [Rev.1/07j (Ieave blank) _. col�fr act 6ici perM14 M if aPPIfcabfe;} r APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachuseits ElwWcal Code(MEC),527 CM. 12.00 (I'IWEPBZN!IYMKOR TYPE ALL17V 'O Date: City or Tow.of: A JQ Z`�t�/OI`JJ To the Inspector of Wires: By this application the undersigned gives notice of his or her fi teat o to perform the electrical work described below.` Location(Street %er) Owner or Tenant7/'i C C Ce J�JIrJE'l� Telephone No. Owner's Address Is this permit 4u conjunction with a building permit? Xes ❑ No (Check Appropriate Box) Parpose of Building Utility Authorization No. R'jstang Service Amps / Volts Overhead❑ Undgrd•❑. _ .No.of Meters New Service Amps. / Volts Overhead❑. Undgrd❑ No.of Meters um cr of ceders and Ampacity Location and.Nature of Proposed EIecidealWork: (J'I,51h'a �✓I�! SCIS�� Co letlon ofth--following table may be valved by the Inspector of Wires. s �✓ No.-of-Racessed Lu-mminair n of-Ceil.=Susp_(Paddle ans No.of Iofat axrsi`orruer�I�"z� � `¢�Y`" No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- _ o.o Emergency rg ung s No.of Luminaires ISwimminngl?'aol axnd. d. ❑ Gaffe 17nits -..-- -- ------------ N6.of Switches INo,of Gas Burners No.of Detection and Initiating Devices No,of Ranges No-of Air Cond. Tonal No.of Alerting Devices HeatPnmp Number 'Eons ICW No.ofSetf-Co- fEined i No.of Waste Disposers Totals: Defecfion/Ale orDevices No.of Dishwashers Space/Area Heating KW Local Municipat El other Connee an No.of Dryers Heating Appliances KW Security Systems--* � rY No,of Devices or E uivalent ' No.of Water M.of No.of Data.Wiring: r Heaters Signs Ballasts No.of Devices or Equivalent No.Hydro massage Bathtubs INo.of Motors Total ET Teleco ofD6iiceio r Equivalent No.ofDevicesorD+ uivalent OTHER: llhcach additional detail ifdesire4 or as reguira by the brspector of Fixes Estimated Value o Eleciricat 1orTe: /070.UO (When required by municipal policy.) Work to Start'-4s t Inspections to be requested in aceordauce witliN EC RLle 10,and upon completion- INSURANCE COVERA.CE: Unless waived by the owner,no permit for the performance of eleCuldcal work may issue tmless the licensee provides proof of liability insurance including"completed operation"coverage or it substElatial equivalent The undersigned cert2tes that such coverage is in force,and has exhibited proof of same to the permit issuing office. CBECK 0N$; INSUBANI CB ❑ BOND ❑ OTHER.X (Specify:) Selflnsured feet*,under thepalm andpelzaltks ofpedWrry,that tFcE i[404 on this appllcadun is true and complete YIRM NAM. ADT LLC DBA_ADT SGGuy' f LIC_NO.: C-172 Licensee: Thomas T.Lee iguafure LIC.TTW C-172 (If applicable.P Y 11 xemot"vi the lice se number 1' �•I Bus.TeL No.: Address.- / ���Ci✓ 'f< 'J `, t Ale '�ciO;' Alt.Tel xSepuriLy System ContractorLiconse required for this work;if applicable,enter the license number harp; 001779 ONM W S 73`FSUldANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally req*ed by law, By my signature below,I hereby waive this requitement. I am fho(cheep one)F1 owner ❑ow_nces agent. • �wder/Agent (� .�`:� '� �---- Sigo.atuxe Telephone No. I ,t� 16A11\3 ."U e lwulzl .r.-65'_ :ys i= `:>:•!'--°_ .{S+'t'.>_ _ Em "= • =[• r^ --�:�r17�. e L•::':i,p�f: :4•.-.4: t'1- l.'`fi4rfi';;�i A'!:ASEJt!_'i•` 1= TS . ( Iit:`� t�.,�} •�(]�(5i�1'ys<-' �1:+_:4?��.=�.1�;�- .,2;•..�.+,.:::\==i�:-r.4i_�:ct: �;�r.���:ld_ _ 1::["sil:' -- '—_:syl..c�L.y_ -_at,,..�>1•;::` �. _ Y Commonai h of t�assatSuseYs r Deparm'ef}t of p!lbl:c safety 4t-c-,aih•Ss�')cmc-S-Lirrnca - L.icense:55-RR177S - `` 1:•S i� jJ, �n { Thomas T IX— u ; GY� o!ad11�R2G9D°: � i �;F.' � Gorrirrriss"wnef (Y,5f1�R'C4 , • i �s t E • 4 9 The Commonweatilt of Alassaeltusetts Departntent of Industrial Accitlenty Office of Investigations > .Boston,MA 02111 1vww:rttrtss.g0V1dir1 Workers' Compensation Insurance Affidavit: Builders/(fontracturs/Electricians/Plumbers Applicant Information Please Print Lggibly Name(T3tr_iint:sslfh aoizatioitlit)dividuiat).. ADT Security Services Address: 18 Clinton Drive City/Statty/Iip;___Hollis NH 03049 Phone#; Are you an employer?Check the appropriate box: 'I.vpc of project(required): 1,EX I am a employer%k►th 1000+ 4 ® 1 any a general contractor and I employees(full andlor part-time).* have hired the sub-contractors b. New construction 2,© I ant a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling; ship and have no employees These sub-oontractors have g, ❑13emolition working; for me in any capacity. employees and have workers' 9. ®wilding addition [No workers'comp,insurance comp.insurance.: required.] 5, ❑ We arc a corporation and its 10,[]Flectrical repairs or additions 3 Q 1 am a homeowner doing,all work officers have exercised their 11.El Plumbing repairs or additions myself:[No workers'comp, right of exemption per iv1GL 12.❑Roof repairs insurance required,]t c. 152,§1(4),and we have no employees, [too workers' 13.R other,Low Voltage comp. insurance required.] ecurity S stem ?,any applicant that chtcks box M most also fill out the section bclow showing their worker::'cotopensalion policy infomlation. t Homeou-ners who submit this affidavit indicating they are doing all work and them hies outsi4e,contractors must submit a new affidavit indicating stack tContractors that chink this box most attached an additional shcct showing the nann of the sub•contractwr and stets whether or net Muse tnttitics have employcr;s, If the sub-contractors have employees,they muss provide their workers'comp.policy number. !ant an employer drat is provitinti workers'compensation insurance for my employees. Below is lite policy and jab site Information. Insurance Company Name ._Zurich American Insurance Co. Policy##or Selfi ins.I.ic,it; WC509589701/WC509589801 Expiration bate:_10/01/2014 Job Site Address: .�� ���. PAS _. C e _City/State/Zip: �L Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration elate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of lute up to$1,500,00 andlor tine-year imprisonment,as well as civil penalties in the form or STOP WORK ORDER and a fine of tip to$250.00 as day against the violator, Be advised that a copy of this statement may be forwarded to the Off cc of investigations of the DIA for insurance coverage;verification, 1 do hereky c709J,under th ]alerts and penalties o,f pedwy that site inforntaticm provided above is rue and correct. 16, 1>l�tme 603-594-5937 Official use on v, Do not write in this area,to he completed fey city or town official. City or Town: Permit/license b _ .Issuing;Authority(circle one): 1.Board of Health 2.Building;Department 3. C ityl`I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector Cr.Other Contact Pers-on: Phone#: DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/25/2013 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 2 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT N Aon Risk Services Northeast, Inc. NAME:PHOE a Morristown NJ Office (A(CNNo.Ext): (866) 283-7122 FAX No.: (800) 363-0105 C) 44 Whippany Road, suite 220 E-MAIL o Morristown NJ 07960 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Zurich American Ins CO 16S35 ADT LLC INSURERB: American Zurich Ins Co 40142 ADT Security Services 1501 Yamato Rd INSURER C: Boca Raton FL 33431-4408 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570051395419 REVISION NUMBER: 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. Limits shown are as requested INSR TYPE OF INSURANCE ADD SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MMIDD/YYYY A GENERAL LIABILITY GLO EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $l,OOO,OOO PREMISES Ea occurrence CLAIMS-MADE X❑OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 °2 GENERAL AGGREGATE $4,000,000 M GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 UD X POLICY PRO- LOC o r AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) O ALL OWNED SCHEDULED Z BODILY INJURY(Per accident) y AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE N AUTOS (Per accident) O w N UMBRELLA LIAB OCCUR EACH OCCURRENCE U EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION 8 WORKERS COMPENSATION AND wc509589701 10/01/2013 10/01/2014 X TO SM - oTH- A EMPLOYERS'LIABILITY Y/N wc509589801 10/01/201310/0l/2014 RVLII TUTs ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $2,000,000 OFFICERIMEMBER EXCLUDED? M NI A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000_ c^� DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) g-�s t J� �-C CERTIFICATE HOLDER CANCELLATION W SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. am-- TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE INSPECTOR OF WIRES �-_'- 124 MAIN ST. �J � /�C� y�/� 'yr �/ �• NORTH ANDOVER MA 01845 USA C�S c�/GIDfO t✓i^LtiICE'�[./l�oy ✓lstGL ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD