HomeMy WebLinkAboutWire Permit - Permits #12618-1 - 96 CAMPION ROAD 8/24/2015\`
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TOWN OF NORTH ANDOVER
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` This certifies that
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has permission to perform � � � S
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wiring in the handing ofNAS
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Fee.. . ..: : ....... Lic. No
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mit No.
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BOARD OF FIRE PREVENTION REGULATIONScy and Pee Checlted
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APPLICATI"ON4 FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CIvITt t 2,00
(PLE-ISE PRINT NINK OR TypL,ALL
ZNFORAL4T10.A9 Date:
Cite or Town of:
By this application the unaersignoc,givF.e nnt,ce of his or her intention to pe formMthe7el ctrical Work described below,
.Location (Street&Number)
Owner or Tenant
Telephone No:
Owner's Address ac l
1
Is this permit in conjunction with n building permit? ]'es '
❑ No (Check Appropriate Box)
Purpose of Building CJtility Authorization No.
.Existing Service Amps / Volts Overhead
❑ Undgrd❑ No, of Meters
New w Service Amps / _Volts Overhead
❑ Undgrd ❑ No, of Meters
' Number of Feeders and Ampacify
Location and Nature of Proposed Electrical Work:
r...�
r ,
Com letian of the follomin=table=3,be ivan)ed by the nspeclor of 91ires.No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans NO, of Total
Transformers KVA
No.of Lumin, Outlets No, of Prot Tubs
Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ a, o emergency ignnng
ind. Qrnd, Batte Units
No. of Receptacle Outlets No• of Oil Burners TITLE ALARMS No, of Zones
Na.of Switches No. of Gas Burners No. of Detection and
Initiating Devices
No.of Ranges INo. of Air Coed, 'T'otal
Tons No. of Alerting Devices
No.of Waste Disposers heat P mp ••N••�.umber Irons KI�i' No, of Self Contained
.... .............
Detection/Alerting Devices »
No,of Dishwashers ---- -•--
Space/Area HeatingKWLocal❑ Municipal
Connection ® Otl'p'
No.of Dryers Heating Appliances Security Systems:*
No. of`ti Heaters IOW No. f` No.of Data Wiring:No.of 17evices or E uivalent
ea a
Signs Ballasts No.of Devices or Eauivalent
Na.Hydrornassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No.of Devices or•1
OTHIJR: uivalent
Attach additional detail if desired, or as required by the Inspector of lfi ices.
Estimated Value of Electrical Worlc: �r (When required by municipal poIicy,)
'
INSURANC
Work to Start: `, Inspections to be requested in accordance with NEC Rule 10, and upon completion,E 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. Time
undersigned certines That such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND > l
Icerti p ❑ OTEIER � (Speciij�:) ��k�-
fy,.unde7,the pains and penalties of perjury,that the information on this application is.r`•rue and complete.FIRMNAN11: ADT LLC DBA ADT Security f'/ i
Licensee: Thomas Lee - LIC.NO.: C-172
Signal"ure LIC.NO.: C`172
(If applicable,
er enl "exemgl" '17 the license number line) ( j C g�
Address: C1C`r !t��t4' , , C2-yam ( )Bus. Tel.Na, iP; La I'1 J*Per M.G.L.c. 147,s.5 7_51,security wos,,requires l) cty Alt. Tel.Noense: Lie, 6
OWNER'S INSURANCE WAIVER: I am.aware that the Licorice sloes not hair�he,liabil ty insurance cove'age normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑Owner El owner's went,
Owner/Abent
Signature-
Telephone e Telephone No,
Ofwee OfInwesd1glaflons
600 ff 7Sh btOn S,"Feet
_g03t,,n,PfA 02111
Vv-w.masy-govIdia
Sion 'Jg, COD, pajRqq lon, nn co AMd1aAtc
Fry-hy-1110911bLy
A
Name
o
>
IM10110 Yl.. ¢ is
City/Statemp:
hype of project:(required):
Are you an e -r?Check the-ploy,F?fl� 4. 1 am a general contractor and f 6. G011stluction-
1, I a m a'em P I o Y o r vT have hired the sub-contractors Rerilodeling
employees(fill and/or listed on the attached sheet.1
2.[11 am a solo proprietor or partner- Jheso sub-contractors have, Dcinoliti011
ship and have no ernp!GYM3 workors., comp.insurance. 9. Building addition
working for me III any'capacity. e 5. E] Wr l
axe a coiToration and its 10,E]Electrical repairs or additions
o workers" cOmP,i`sutanco officers ha-va f-,xercisedtheir 11.E]Plumbing repairs Of additions
1equired.] al right of exemption per MG:,G
3.0 1(am a homeowner doing,,I work c. 1(4),and via have 110 12.[]Roof repairs
myself [No workers
camp. ei)loyces. No workers,
A14 1
insurance required.] m I J Other
comp.insurance required.]
beloly s1lowing qlcir y�,ozkers*comPensatio I Polky infonnation.
ust also BA out the sectioa binit aney,affidavit indirating siich,
_Any applicant that checks box 41 m , a doing auworl-,and then 11i[o outside contrador I must su V k 0 Im irz information.
j I-romeo),nar,�yjja subInit this afFidavit indicating they ar ontra, -s and fl,�!r� or ers' 0 F,Po"GY 01 5et shoj�vljg tba name oftha lb-r to,
TCGIIL.ractols ffiaL chael,this to,,must attached an additional A --- ey. Below is 1110polley aWfjub SM?
tv'Pro-Pidigg COMP"I"Yat"011 Ins-T)Fat!cefor rr-'y elIT 10ye
Or
information.
Insurance Company Name:
A.A.
Policy#Of Self ins.Lie.
--A)
City/State/Zip:
rob SlfoAddrp-ss: -nber cnmsa '011 poliq (8110Y'Ingf1leV01'ry11103,of rimffial paualtics of a
Utach m colpry of the workars,compe 1�2 can load to the IMP Ositi WORK fine
Lire coverage as required under Section.25A of MOL STOP ZK()pDFR and a f
!ailuro to see one-year imprisonment,as well as civil penalties in the,form ofaS "Ice forwarded to the Off Of
ario,up to$1,500.00 al�d,/or On advised that a GOPY Of this state"nont may be fo
)Fup to$250.00 a day.agaifflt the violator. Ba tion
4
.nvestigations of the DM for insurance coverage Veri
and corroc'
ag gle in f orr-willonp?o vjdPd above
qghy Ffi "inder d;�)-mder gj .`,4
Date.
)horn
by clay or�Olvn offix1af.
PrItc in ifils arell'.to be CO- d
OfJ77eldflusconly. Donotl
city or Town:
Issuing AuthoxftY(Chrc-10 0"0)'-" (,'Ie--,-k 4.0ectricM RISU"for 5-
L Board I of Health 2.Building DepartMe"t 3�
6.Other
ph Gont:eW
Contact Ferson:_____
CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDYYYY)
10012014
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 PHONE Ext): FAX No)
Sunrise,FL 33323 E-MAIL
Attn:FtLauderdale.Certs@marshaom ADDRESS;_
INSURERS)AFFORDING COVERAGE NAIC#
048953-ADT-GAW-14-15 INSURER A Zurich American Insurance Company 16535
INSURED
..—_ _....._.. _ _ _
ADT LLC INSURER B American Zurich insurance Company 40142
18 Clinton Drive INSURER C
Hollis,NH 03049
INSURER D
_..._..._....__.._._...-
INSURER E: I
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 CLAIMS11-111-11 .
...
INSR ',ADDL SUER . ---- POLICY EFF-7 POLICY EXP ---- --- "
LTR TYPE OF INSURANCE --_"LI _ ------
' WV POLICY NUMBER MM/LID/YYYY MM/DDJYYYY LIMITS
A GENERAL LIABILITY GI.O 5095899 02 10101/2014 10/01/2015 2,000,000
_._......, I EACH OCCURRENCE ___ I $
X COMMERCIAL GENERAL LIABILITY t )DAMAt;E r6_R_FNTE� 1,000 000
--.- __. - ;_PREMISES(Ea_accurrenc� $
CLAIMS-MADE X"I OCCUR MED EXP(Any one person) $ 10,000
____ -... .. PERSONAL&ADV INJURY $ 2,000,000
GENERAL AGGREGATE $ 41000000
GEN'L AGGREGATE n F.LIMIT APPLIES PER: ! PRODUCTS-COMP/OP A( $ 4,000,000
PRO --- _.
X POLICY LOC $
B AUTOMOBILE LIABILITY BAP 509590002 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000
�_..- (Ea accident) $
X _..-
-.- ANY AUTO _ I BODILY INJURY(Per persorQ $
ALL OWNED "- SCHEDULED BODILY INJURY Per accident $
AUTOS _.. AUTOS ( )
NON-OWNED PROPERTY DAMAGE ----
......_i HIRED AUTOS --_ AUTOS ..(Per,cadent)........
-____-- UMBRELLA LAB OCCUR '..
EACH OCCURRENCE 'S
-,,....- EXCESS LIAB CLAIMS-MADE.. AGGREGATE $
DIED RETENTION$
B WORKERS COMPENSATION WC 509589702(AOS) 10,10112014 10,101,12015 X VVC STATU- I ,OTH
AND EMPLOYERS'LIABILITY ',I TQRY LI MS ER
A _--_ _
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC509589802 (MA,WI) 10/01,12014 10/01/2015 2000000
OFFICER/MEMBER FXCL.UDEp? N NIA: E L.-.EACHACCIDC
_"".- NT $
(Mandatory in NH) F.L..DISEASE-EA EMPLOYEE$ 2,000,000
If yes describe Under -- -- "---_ - ----
DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT ,$ 2.000�000
1 �
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
ATIN: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 Mukherjee T" nx a-c>aati gd�aL...r tr r
Oc 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD