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Home My WebLink AboutWire Permit - Permits #13360 - 31 CANDLESTICK ROAD 6/9/2015 ate. ............. \\ IMMENSE TOWN OF NORTH ANDOVER VIM IN O o PERMIT FOR WIRING \ � fia S HU�� ow °\ In This certifies that _.,,_._ ......,._ ._.. . ... _,e - - v.................... A \\ WIN \� IN his permission to perform ......... ... ........................... M M wiring in the building of,.. Me— v go at ..,. ............ Ierthdc�ver Hass, OWN vy Fee.......: MINI Lic. lc�. ..\ __ ,.....,.. Ec rxc � INSPECTOR L \ mom Check ..-.- nmonulea.GLr%o� i�a:sJactivaeic� O��rcial Use pnly� . ❑ an tm «t o c J freer FfxeA, oBOARD OF FIRE PREVENTION REC,U — ant)'and Fee Checked LA!IONS 7] - ----- ��i��¢�� (leave blank) R FOP, PERMIT TO PERFOi� ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(jvmc),(PLEAETI PMYTW INK OR TIrPE ILL INFORh14T10N City or Town of: �,, Date: 527 CMTt 12.00 By this application the undersigned gives notice of ns or he iIi tention top form the eI tr�c�]vv described Location (Street&Number-) below. Owner or Tenant Teleplfane No: 'Co Owner's Address Is this permit in conjunction with a building permit'? Yes \ Purpose of Building ❑ No (Check Appropi late Box) Utility Authorization No. Existing Service Amps _Volts Overhead ❑ Undgrd❑ No, of Meters New w Seri,iice Amps /�Volts Overhead Number of Feeders and Ampacify ❑ Tlndgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Com letionn of the jollowin table maybe tncziiled Gp tlne L7specto, of T�'ires, No. of Recessed Luminaires No, of Ceil.-Susp•(Paddle)I ans No. of Total No.of Luminaire Outlets Transformers ICVA No. of Hot Tubs Generators TCVA No.of Luminaires Swimming Pool Above ❑ in- ❑ Bo. o irnergency ignnng att Units �i nd. �rnd• e � No.of Receptacle Outlets No. of Oil Burners — _ WRE ALARMS No, of Zones No.of Switches No, of Gas Burners 1V0• of Detection and No.of Ranges Initiating Devices INo.of Air Cond. Total 'Pons �No. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained Totals: ................_..................._..._-.._............................... No.of Dishwashers Detection/Alertin Devices Space/Area Heating KW Local❑ Municipal No. ofDryers Connection ^❑ OPhar Pleating Appliances IC.�, Securif�,Systems:* "-Z, o. of Water No.of No.of devices or E uivalent Heaters ICW No. of Data Wiring: Signs Ballasts No.of Devices or E No.Hydromassage Bathtubsquivalent No.of)Motors Total HP Telecommunications Wiring: OTHER: Na.of Devices or E uivalent ?a Wonal detail1fdesiz•ed,, or as required b� the hnspeczor of lficires. Estimated Value of Electrical Warr. _ p, (When required by municipal policy.) Work to Start: `> • Inspections to be requested in accordance with MEC Rule 10, and upon completion, INSURANCE COVERAGE: Unless waived by the owner no permit for the erfoirnance of electrical work may issue fhe Iicensee provides proof of iiabilits insurance including"completed operation"coverage or its substantial equivalent Theess undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. C MCIC ONE: INSURANCE ❑ .BOND ❑ OTBER � (Specify:) .`�t'.��`' eertify,.untler thepaizzs and perzcz F ltles o er ur tizat the irzfornzation on this application is,tlwe and complete IRMNAMI: AI7T LLC D13A ADT Security i Licensee: Thomas j, LTC.NO.: C-172 Lee �i` Signfiure / /� -�_ LTC.NO.: C-172 (If applicable,enter "nxemgt" h the license num e6r`line) ,K _ Address: ® s--``= ice. \ f Bus. Tel.No. ,r Per M.G.L,c, 1477,S.57-61, security Alt.Tel.No..` � wore;requires!)T'a,dtrxent ofPublic safety"S"License; Lic.No. S C7U J 7'� -OWNER'S INSURANCE`YAIVER: I am.aware tliat the 1_,iccnsee does not haa)' the liability insurance coverage)Canal required by law, By my signature below,I hereby waive this requirement. I am the(check one) ❑aance Owner/Agent ❑ owner's Signature Tele hone No, p R F5R�� ❑� s ... M Department of Indusgii4alAccidents Office ofln-Vesfigadons 600 Woshington SifFed Boston,311A 02111 RAJ 5'�Uv4 ww.mass.govIdia W orkers, Compensation MusuranceAffidavit. 10' —64-se Print IG b ty A He�nt Inform—atiall -— Narrf 0(Businese/Orgal3ization/Indiyictllgl)-% ; Address: C y--gc city/stata/zip: tAo Are you an einployer?Cheelk the Appropriato box- Type of project(required): 1,L��I am a'employer \0061.Y 4. ❑ 1 am a general contractor and 1 6. Ll New collstructiOn. emp — -�-:— have hired the subcontractors employees(full and/or part-time).'` listed on the attached sheet. 7, []Remodeling 2.F] I am a solo proprietor or partner- These sub-contractoys have S. r]Demolition ship and have no employees workers, comp.insurance. 9, F1 Building addition working for me.in any capacity. We are a corporation. El poration and its [No workers' comp.insurance 5 10,❑Electrical'repairs or additions officers have exercised their required.] right of exemption per M(3L 11. Plumbing repairs or additions 3, 1 am a homeowner doing all work c.152,§1(4),and we have no 12.0 Roof repairsmyself. [No workers'comp. employees. Wo WOTIcPrs' 3 0— Other insurance required.]f I comp.fiasuranco•required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Rorneovvners who submit this affidavit indicating they aTo doing all work and then hire outside contractors must submit anew affidavit indicating such. lConlractma that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.P0liGY inf001at30n —. inforillation. m Insurance Company Name: Policy I or Self-ins,Lic.9: -`7 City/State/'Lip: lob Site Address Attach 9 copy of the worlrersl corflipensation policy declaration page(showing the poijeynamberand expiration date,)- Failure to secure coverage as required under Section 25A of MCTL c. 1S2 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 acid/or one-year imprisonment,as well as civil penalties in thf-,f - form of a STOP WORK ORDER and a fme Be of up to$250.00 a day.against the,violator. advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ver14:,-,af1on. t c0l"ce?' 1(10 Hereby coraAv Ender tile Ifigt the infornza-joig provided above is i (I ^ 1 ti Date: AQ Phone#: Official ase Only. Do not Pprite N iN .S are(t,to be conWfeted 1xy city or tow"official City or Town: Permit/License .Issuing Authority(Circle one). vjn Clerk 4.Electrical inspector S.Plumbing Inspector &y/To'I'l'Y'A .1.Board of H. ealtil 2.Building pepartmeut 3.Cit dn'b 6.Other Coatsi t.r Phone iv- ontact.Ferson. ACC>R CERTIFICATE 01= LIABILITY INSURANCE DATE(MM/DDlYYYY) 0i08/2014 __[: 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 _. __......awgrass Corporate Pkwy,Suite 300 PHONE FAX Sunrise FL 33323 No,Exq. _ (A/C,_No): E-MAILE-M _ - ...___.. Attu I'LauderdalaCerts@marsh,com ADDRESS. 048953-ADT-CAW-14-15 RERS)INSU AFFORDING COVERAGE _ NAIC# INSURER A:Zurich American Insurance Company �16535 INSUREDAmerican Zurich Insurance Company ADT LLC INSURER B: P Y 40142 18 _ — Clinton Drive INSURER c Hollis,NH 03049 INSURER CI .. .... .... .. ..... ... 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. INSft. .....-. ..-.- ...._LTRwvn -TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP " " --- -- ' MMlDD1YYYY ( LIMITS MM/DDIYYYY LIMITS A GENERAL LIABILITY �GL0509589902 10/01/2014 10/01/2015 2,000000 EACH OCCURRENCE __ $ X.. COMMERCIAL.GENERAL LIABILITY DAMAGE TO RENTED 1,000 000 PREMISES(Ea occurrence?_ $ CLAIMS-MADE X OCCUR MED EXP An one 10,000 --_ (Any Person? $ -. -- -....... PERSONAL..&ACV INJURY S 2,000,000-- _---� -" -- ---- GENERAL AGGREGATE c 4,000000 GEN L AGGREGATE LIMIT APPLIES PER X ( POL lcv PRCT Oc PRODucrs-COMB/oP AGO 4,000 000 _ $ B AUTOMOBILE LIABILITY BAP 5095900 02 10/01/2014 10101/2015 C.'OMHINED SINGLE LIMIT 1,000,000 X , LFa accident( S ......_.. ___... ANY AUTO BODILY INJURY(Per erson S ALL OWNED ! SCHEDULED P _ AUTOS {I UTOS NED � � BODILY INJURY(Per accident) $ HIRED AIJ IOS AUTOS PROPERTY DAMAGE -- $ - (Peracadent)— _ UMBRELLA LIAB OCCUR CACJhlC7C;(�UFvRENCC -� EXCESS LIAR CLAIMS MADFI f - - AGG_REGAIE DELI RETL-NTION$ WORKERS COMPENSATION $ L YIN r r �_TORYLIMIT C7TH AND EMPLOYERS'GXCLLITY CAC,H AGC;I LIABILITY JVC o0u5897 02(AOS) 10/0l�2014 10 01I2015 X vrC TA rU A ANY PROPRIETOR PARTNER/EXECUTIVF WC;5095898 02(MA.WI 10/01/2014 10/011'201u S ER 2 000 f100 OFFICES MFMBER UOIzDf N� N/A E,L DENT S It(Mandatory escr b NH)nd J F I DISEASE EA EMPLOYEE S 1206,000 If yes,describe under � _ DESCRIG'TION OF'OPERATIONS below E L L)SEASE POLICY LIMIT '$ 2,000,000 i i DESCRIPTION OF OPERATIONS)LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Town of North Andover Is Ind ided as additional insured(except workers'cornpensation)where required by written contract, CERTIFICATE HOLDER CANCELLATION Town of North Andove';r AT7N Electrical Inrtl'mrtpl SHOULD ANY OF THE.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE, THEREOF', NOTICE WILL. BE DELIVERED IN Clorth frnrlr per, 'AA 0"89 N M'l ACCORDANCE WNTH THE POLICY PROVISIONS. nr !S AUTHORIZED REPRESENTATIVE of Marsh USA Inc. IManashi Mukhrvjr e s;>1988-2010 ACORD CORPORATION. All rights reserved, ACORD 25(2010/05) The ACORD rlarrle and logo arc registered marks of ACORD