HomeMy WebLinkAboutWire Permit - Permits #11859 - 333 CANDLESTICK ROAD 9/16/2013 ` `\
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130ARD OF MRE PREVENTION REG-, TIONS
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[Rev.11071 q-va blank)
APPUCATION FOP, PERMIT TO PERFORM ELECTRICAL WORK
U work to be performed in accordance wife the Massat huscffs Electrical Code CkE,Q,527 PM 12.00
(TLEAYEP=IIVB�KORYYPE,ULINFORMATYON) Date:
City or Town d: AIWI) AnlJllillk" To the InTector of Kres: ;: i'
By this application the undaH,gaed gives notice the P�leotricalworlcdesmb54below.,
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fA cation(Street 8--Number) 7,
Owner or Tenant
Owner's Address
Ts this permit in conjunction with a buUding pei roit? Yes! ❑ No (Check Appropriata,Box)
Purpose of 137-ii1ding Utility Autboriz,2tlon No.
X�jsting se).-vice Amps Volts Overhead F] 'U'adgrd. Wo.of Meters
New Service Am T ps. _V1 0 its Overhead[I. UndgrdE] No4 of Meters
I�—am-T—er—oYseeders and_A m 1)aTit,y
Location and Nature of Proposed Electrical Work: L'4)'514LZ(
CorgpfefiOn of the following tabte may he werNed by the Inspector of
Fires.
No—of Total-
No.of Lumimalre Outlets No.of Hot Tubs Generators KVA
N __
No.of Luminaires swinuniuffpool Above In n o.6 fXJ Her�gency 11gQH9
grad, d. Batte Units
-of
Nb.of Switches No.of Gas Burners No.o Detection and
Euitiating
No,of Ranges No..of Air Concl. Tons/ No.of Alerting Devices
No.of Waste Disposers Heat Pamp I Number I Tons I KW No.of Self-Con ined
Totals: Defecf1on/A1e or* Devices
No.of Dishwashers Space�Axea Heating XV cat❑[�Muu'c'PF' El Other
1
Connection
No.of Dryers Heating Appliances im Securit
No.of Devices or Yq11Livalc)1t
No.of Water Data Wiring.
Heaters xW Slams Ballasts No.ofDevicesorFqu alent
Na.Hydra ruassage Bathtubs INN.of Motors Total B11 Telecommunications Wiring:
No.of Devices or Equivalent
OTBER:
,4 ach ac'*tibnaf detail rf desirg or as required by the Inspector of P71rey.
Estimated Value o Electrical Work: p (When required by municipal policy.)
�Work tl start luspecdons to btrequesk;d in accordauca with Y=R-Lll(-,10,and upon completion..
INSURANCECOVERA,(.1B. Unless waived by thf,owner,no peru6A for the performauct,of elcctical work may issue unless
the Hobuseb provides proof of liability iasacanct.-ii-ichilding'c_ompltted opei-6ilon"co-vffimgG or iL-substantial equivalent The
undersigned Gortifirs that such coverage is in form,and has oxEbitod proof of spmo to the permit issuing ofu'cG.
CHECK ONE, INSDRLWCE ❑ BOM) El 01TIER.X (;specify:) Self 1iomred
X c e rtflj:,under fliep auzy mid p en a XP ofT arp-ry,that tli a rFal'arm,aL�w,on this app Zic ado rk is true acid c o mp fete.
1-�JRM NAM..-A.D.T.LLC DBA ADT Security LIC.NO.: C-172
.Licensee: lliomns T.Lei) ignature f LIC.'NO.: C-172
(7f appzLab!'. 11
r en oil t"Ll Bus�Tel.No.:
Address-, VV-6: -Ut TeL Xo.:(�Oc3
`8ecurA-y System Contractor iWilse required for this woriq if applirable,enter the license n=heF hare 001779
OWNER'S TSL7ztA1VrC WAIVER I��n a-�YaiD 01-ftho Licensee does not have the liability manlauc-P,coverage nol��Y
rl
required bylaw. laintho(check one)EI owner [lownff'sagent
CYWULr/Agent 11 -
Signature Telephone No.
_41boC) 9q CA
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rrizga"�'�kn� 1Jn�9�ranc,._,,A �?l r.?o I �Ar T d - �TtC .l:YY¢ P n' �G it
_ ADT Security Services
, dry,s: 10 Clinton Drive
diqG ` 0300 _ a � �99 7,0
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8�r�Y�,��rs4�Y-rG�r`c��n�t*e3'can� ,�1�work - �' �_.
myself, [No-workers'comp r104 it ANIGL
nsum cc,requ�r LaVv Voltage
tramp.insurance t°equirefli Secure � S$C'6'fi
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JI'nsuyance Gampi'y Naas,... Zurich American Insurance Co.
tz tNC5095897 00/WC509598 00.._"_ 10/01/2013
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fifrac i, p to('$1,50UR Owlictlor cm yc_.,'ar. a mpmonment io, %Ya:il as civil pc r,�Yltics in dic f'bm of a S F 1I hVl(;1.4t ()t�[3t R�wd a fly-to
ctrfup to V TWO a;CIAY V>ObimL 44L`;'4lnlakir, M a4'v1re.d that a naky bo,Esrnwour etl to ffic Of cc of
r]Yra t� $ �d7ta o fthe DIA for I ra-spasm w t?:uver g
- d-''0/d�°I2,rIG'cg'IY.._V"'jfnak°N 3't a'S$dk:p"a,ddaslv a'71iP`' ry k�'Jj(tlJ"..d*-G�:( ,d'h ai'-PY&£zdti''.a "2alAb'it'_ti?d.
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CERTIFICATE OF LIABILITY INSURANCE DATE„10112012( YYY)
�►,...r.-� 012
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
1166 AVENUE OF THE AMERICAS PHONE FAX
(A!C No.Extl ....._....... .. _..-..-—_—....._...._ (A/C,No)
NEW YORK,NY 10036 E-MAIL
_..—L
ADDRESS:
INSURERS)AFFORDING COVERAGE NAIC#
048953-ADT-MAIN-12 13 INSURER A:Zurlch American Insurance Company 16535
--.... - --- ---- - ... - — --
INSURED INSURER 8 American Zurich Insurance Company i40142
ADT LLC
18 Clinton Drive INSURER C:
Hollis,NH 03049
INSURER D:
INSURER E
_ INSURER F:
COVERAGES CERTIFICATE NUMBER: NYC-006524016-01 REVISION NUMBER:1
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; ........._ .-..-__.._.—.._...... ADDL SUBR' ........ _..... —_ POLICY EFF POLICY EXP..�...._ ----. --.-- ........ -
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MMIDDfYYYY LIMITS
A GENERAL LIABILITY GLO 5095899-00 09/28/2012 110/01/2013 EACH OCCURRENCE $ 2,000,000
X DAMAGE-To RENTED —
COMMERCIAL GENERAL LIABILITY PRFMISFS(Ea ocrurrence), $ 1,000 000
CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000
-__-. --____----..._..---..... PERSONAL&ADV INJURY $ 2,000,000
...... ----. — _... -. GENERA.AGGREGATE $ 4,000 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 4,000,000
X POLICY ..- PRO' __....
T I LOG S
AUTOMOBILE LIABILITY '... COMBINED SINGLE LIMIT
(Ea accident) S
ANY AUTO BODILY INJURY(Per person) $
--..;ALL OWNED __...... SCHEDULED
BODILY INJURY Per accident $
_. AUTOS _..__ AUTOS ( )
NON-OWNED
HIRED AUTOS PROPERTY DAMAGE _---
I - --___.. AUTOS � (Per-acddent) $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS MADE AGGREGATE
__ I $
._ -..._-. _ ...-----...
DED I i RETENTION$ ....... _... __..
E WORKERS COMPENSATION WC 5095897-00(Deducflble) 09/28/2012 10/01/2013 X I WC STATU OTH
AND EMPLOYERS'LIABILITY - ....._TORY LIMITS L ER
ANY A (Mandatory in NHREXCL UDED ECUTIVE IY�,N N/A IWC 5095898-00(Retro) `09/28/2012 10/01/2013 E L E DISEASE ACCIDENT
EMPLOYEE,$ _ 2,000,000
EA 00 000
If yes,describe under =-- ..SE- -.--- _.--
DESCRIPTION OF OPERATIONS below E L..DISEASE-POLICY LIMIT $ 2,OOQ000
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
INSPECTOR OF WIRES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
124 MAIN ST, ACCORDANCE WITH THE POLICY PROVISIONS,
NORTH ANDOVI-k VA 01845
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Cynthia Y Kim
CO 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD