HomeMy WebLinkAboutWiring Permit - Permits #12819 - 79 CHICKERING ROAD 10/14/2014 Date......................'.....................
t4ORTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
gg�CHUS�
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This certifies that ....�j., Y �� r
....... ........ ......... ........ .........
has permission to perform ...... ....,. . ' � ................
wiring in the building of................. ............................... ................................................i o-
f
at ........ .. .....: ..:.. t..!....: :.`. ,.N,orth Andover,Mass.
j Fee Lic. No.( .....`... .
ELE 'RICAL INSPECTOR '
Check# L
0
Commonwealth of Massachusetts Official Use Only
Department of Fire Services PormitNo,—
P rm Iq
A BOARD OF FIRE PREVENTION REGULATIONS FOcoluipm-icy and Fee.Checked
tdcfan's Coll V.11071[Rev.
APPLICATION FOR PERM,r TO PERFORM ELECTRIGAL WORK
City or TO WA of.,. Y -o To t776 1 lispectoi f TTIms.
q : elp
By this application the undersignedcyl-kq no"ficc RiatPnti0utPPerf0r1uthe I rf a 11,1ork-described below.
Locatio.a,(Street Number) -P
_77TT-7
-Mlnd L
9�m& �e -- o
0imeesAddre,gg
C V10
Is this permit in co 4- uJaction"ith a building Perm it? yes ❑ No (Cfieck Approprhate)3ox)
llurpose ofBn-vdin —UfffityA nutharizatio No-
9xistfngservice— Amps I "dolts Overhead Undgrd
NeIw ServIc Amps Vol& overbea a El unogrd El No.of-Tyietrs
Numb"of Feeders and AmpacIty
Location a)ad Nature of proposed Electrical Mor.jt:
7 ec(i e—j
C07?Tkd0n offbfefollowfiag table ina F113res.
y he ivalved by be InsP ector of
No.of Recessed Luminaires, No.of Cdl,Susp. JNIo:of Total
Tr usfoxnaers XVA
N`0-Of Lun1bajrc;OutjCt3 No.of Hot-Tabs XVA
Above Xg 9
No.of MmInalres! S�Vvihmffigpool a,0 'Wergency Lg
dy. El Ragey bits
No.of ReceptaclelNo,of Oil Buruers FIRE ALARM,--J-Xo.of zo)),c.,
No.of Switches No.of Gns)3urners 1N0.01 PMCUO."a and
lrxitlatixx vices
Na.of Ranges No.ofAjrCoud. Total'Sons No.of A)erAfttg Devices
No.of Waste D�,sposers Heat.Pmup Number Tons KW !ISTo.of Self Contained
Detectlou/Ale g Devices
No.of Dishwashers ISpace/AreaHeating XW Flodher
omieciion
No,of Dryers HeatingAppMiuoes �Security, ystems:`
No.of Devices 0 nt
No.of Iva- r RW No.of No.of
Heaters
I - .3 Ballasts NO,of Devices or E uly0ent
HlydroxvasgageBathtubs N of Motors IT Telecommunicatiory-P AM
Na.of 1) es.1 Y91111"
t i
.4aach a&Iftfonzit detail ifdefire,�or as reqvtredbytlieriispecto,-of jvires,.
Estimated Value o:f lochic Pork: L/I• i
(WlejireqnTxodbymuoicipalpoRcy.)
Work to Start, Inspectionstobe requestedin accordance y�?fhAIECPili.olO,and upon.complati.on.
MURANCE,COMAG)k Unless waived by the ovmerno permit for the performance of electrical work ray issue unless
the licensee provides proof of liability iusuralice.including"comploted.operatdon-,coverage or its substantial equivalent..The,
mdersigped cerfifieg that such coverage is in.'mcO,and has oxhibitea proof ofsamr,to the permit issuing office.
CfMCK OhTF: )1,T80WNCF, El BOM) F1 OTHER.X (Specily.) Self-fusured
--
I cerlif,rinder the pahis arzdpeiuzlfies ofperjuly,!fiat t['e!7'f0rJnqff0-n 011 this application iY true and complete
FIRMNADM ADTfLCDBAADMr=T3, LICNO.- C-172)
Vicensea: Thomas J.Lee LTC No,; C-177
(1j-qPP7tWb1e.—enter-
in 611 license numbept'Ane.) Bus.Tel.wo.z-
Address: Alt.Tel.No.:
System("0114"'rLicelise;rcqukea�br this work,if applicable,enter the license numberhere: 001779
"SecurityLd— - S
UPMER'S INSTUTRANCE WAIVER: I am aware that the Licensee,does not have the liability insurance coverage normally
,,,required bylaw. Bymy signature bclo-,)�1hereby waive this requirement jamfbe(ohcck s
012c)0 oiynor El owner's agent
O
ftnwner/Aggent
attire
T016phoAe Na.. PFA7p iT
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^��® CERTIFICATE OF LIABILITY INSURANCE DATE t0108/2014 /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/C,No Ext:
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 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 INSR WVD POLICY NUMBER MM/DDIYYYY) (MM/DDNYYYI LIMITS
A GENERAL LIABILITY GLO 5095899 02 10/01/2014 10/01/2015 EACH OCCURRENCE s 2,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000
PREMISES Ea occurrence $
CLAIMS-MADE M OCCUR MED_EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 2,000,000
GENERAL AGGREGATE $ 4,000,000
4 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000
POLICY PRO-
B $
X JECT
B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000
Ea accidert $
A1NY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) S
HIRED AUTOS NON-OWNED PROPERTY DAMAGE .._S
AUTOS Per accident
X
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 I WC STATU- OTH-
AND EMPLOYERS'LIABILITY YIN TORY._LIIIMITS ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE NIA WC 5095898 02 (MA,WI) t010112014 10I0112015 2,000,000
E.L.EACH ACCIDENT S
OFFICERfMEMBER EXCLUDED? ----- --
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000
If yes,describe under 2,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
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 MukherjeeC.tLv�oo�
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents
w Office of-Investigaations
d 600 Washington ,Street
t Boston, MA 02111
www.maass. ovIdiaa
Workers' Compensation Insurance Affidavit: ]Lucille rs/Cont>ractors/"�Elect>riciaiis[Plumber<ps
A'laplica nt IIInfolt- nationn (dense Print ILegib
Name (Business/Organization/Tnd�idulll)„_n_ �`�'•�-� � _._7 C � � �y
Address:
City/State/ 'ip: '�E'> \V 1 t Phone # t 1 _
Are you an employer? Check the appropriate box: 'Type of project(required):
l.F&I am a employer with:\0C)0't" 4• I am a general contractor and I 6, ❑New construction.
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 1.3.0— Other��O V4 \l o\"�,-6-1 le
comp.insurance required.]
t Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information`_._•�_e_
I aria an employer that ispr-ovidiitg rvorl(ers'corrrl)ens(atiora insurance for my enfployees•. Below is the policy aced job site
information.
Insurance Company Name: ,;., r : .7 a ,'. �� i{s
_ _,d..
Policy#or Self ins.Lic.4: ,
!� Lo Cit /State/Zi ✓'V 0d
Job Site Address: l r/�-G'r�l Cif Y 1
Attach a copy of the workers' compensation polic>�eclaration page(showing the policy number and expiration date). 0 �°�°r�`"A!3
Failure to secure coverage as required under Section 25A ofMGL 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
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 veri-E: ation.
I ado hereby certify-under the painslrrrzaf°r)en.altieg,"ofperjury that the info rin atioif provided above is trace(ind correct.O
-
Si'attltP".) .w �, Date: .�
� .
F
Phone#: G_�0 c
®fjr"cial use only. Do not write in this area,to be completed�y city or town official.
iCity or Town:_ _ Perinit/License# _-�_---
Issuing authority(circle one):
1,hoard.of Health 2,Building Department 3. City/Town Clerk 4. Electrical Inspector J,Plumbing Inspector
6.Other
Contact:Person: _-- Phone#: _