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Home My WebLink AboutWire Permit - Permits #12929-1 - 2 ELLIS COURT 12/7/2015 m, sit ate .... . ... .... �\ o o VE \ pi IMMIL Tvvt4 OF e► ,, g�m FOR 0 . -.4 z 11 \ 1, ONE * 1,r MLISM agmumg- W.40 Irk 1 :41 - IN _ e,a certifies that Ttii = 107 g\mmm to .... h .................. . . .. ~� lsson P as of .: .• lover,Mass. I e hn�Iin ,North An I'M �� 'win in t ` \ \o .. ... .. IN at \ c cx�ca Lic. o \ � \ \ BEER Gh In \ ee AN \\ �` . .. ` Y nanWnwea i1l.o, N/ ;r,a ct e,r�eiCa - C��cra1 Use C?nly --� sV i e�,a„� „{o f (lye ��'77 L[Rov. t Nc, I Jeraice6 f BOARD OF FIRE PREVENTION REGULATIONSancy and Fee Checked 07] (leave blank) APPLICATI-ON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with th-Massachusetts Electrical Code(lvmC), 527 CMR 12.00 (PLEASE PMTT.W.INA'OR=PL IQLL WFORAdAT1O 9 Date: City or Town of: t",' �� , ` To the Inspector of WiPes,' By this application the undersigned gives notice of�hrs or her intention to perform the electrical work described below. Location (Street&Number) Owner or Tenant � � --- — - - Telephone No: —_ -� Owner's Address Is this permit in conjunction with a building permit? Yes ElNo ® (Checlt Appropri Purpose of Building ate Box) Utility Authorization No. .Existing Service Amps / Volts Overhead ❑ Undgrd❑ No, of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion efthefiollo-,ping table maybe waived hp the Inspector'of lures. No.of Recessed Luminaires INo,of Ceil.-Susp. (Paddle)Fans No. of Total No.of Luminaire Outlets Tz ansfarulers ICVA No. of Hot Tubs Generators KVA No.of Luminaires Above I - . Ba. a rgency zgSwimming Pool r atte, nnng ,Units No.of Receptacle Outlets No. of Oil Burners (FIRE ALARMS No. of Zones No.of Switches No. of Gas Burners =olDeiection andintr Devices No.of Ranges INo. of Air Cond. Total Tons INo. of Alerting Devices No.of Waste Disposers Heat Pump Number Tons I{V4' No. of Self-Contained Totals: "' Detection/Alerting Devices No.of Dishwashers Space/Area Heating I{W Local❑ lYiunicipal OIh Connection Pr No.of Dryers Heating Appliances I{ , Securit3,Systems;' No. of Water No.of Devices or E uivalent �' I� Heaters Na, of No. of Signs Ballasts Data Wiring: No.of Devices or Equivalent No.H•ydromassage,Bathtubs No.of Motors Total HP I elecomznunications Wit-ing: OTHER: No.of Devices or,E uivalent Estimated Value ofElecttical Work �ittach additional detail if desired, or as required by the Inspector of TAT"ires. ° � - (When required by municipal policy.) Work to Start: �RA Inspections to berequested in accordance with MEC Rule 10, andupon completion. INSURANCE 0) Unless waived by tine owner,no permit for the Performance,of electrical work may un the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent•Thleess ,. undersigned dertifics that such coverage is in force,and has exhibited proof of same to the permit issuing office.C1_BC1C ONE: INSURANCE ❑ BOND ❑ OTHER I certify,linden the Pains and penalties of perjztry,that the ti�fornzation on this application i.,true and.complete. FIRMNAMII: ADT LLC DDA ADT Security Licensee: Thomas J. Lee u LIC.NO.: C-172 Signre LIC. NO.: C-172 (If applicable,enter "exempt" 'n the lice se Winn et'line.) K_---------- 'Ter t_ Address; \ C ClCt q � � SS: -t O Bus, Tel.No. � L.l^ 'Per M.G.L.c. 147,s.57-61,security worn:requires j� � Alt.Tel.No., i L .OWNER'S INSURANCE WAIVER: I am.aware thatthe Licensee dae.r not have the liability insurance ety License: rccoverage normally� required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's a_gent. Owner/Agent Signature Telephone No, �PUA��ITFE��` I � t i � ' � r The Commonweyltla ofMassachusetts - 1)epcaitnient of IiWustrialAccirlenfs L 1 Congress Street, Suite 100 www.mrrss.gov/ilia Al"orlcers'Compensation Insurance Affidavit:Builders/Conti-actors/Electrici ins/Plumbers. TO BE FILED WITH TI-IE.PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): _ [ ��?: '� C _ Address: ` C r � c� r City/State/Gip: ® Phone#: � �� l Are you an employer?Check the appropriate box: 'Type of project(required): I. et am a employer with ,.0 i`l employees(full and/or part-time).* J. New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in S. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.®1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 1 ❑ Building addition ensure that all contractors either have workers'cornpensation insurance or are sole 1 .�Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.M i am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs Thesesub-contractors have employees and have workers'comp.insurance.,* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0Otlter �rJ 152,§1(4);and we have no employees.[No workers'comp.insurance required.] \ *Any applicant that checks box 41 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. tContractors that check this box must attached an additional sheet showing the name ol`the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing ivor/ters'compensation insurance for my employees. Eeloiv is Ili policy rind job site it formation. 4 Insurance Company Named Policy#or Self-ins.Lie. #; �""4twes �S Expiration Dater t Job Site Address: o City/State/Zip: cejs Attach a copy of the workers'cornpensation palrcy declaration page(showing the;policy r im—bez and expiration gate). � Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct. Si nature: Date: Phone#: Go r- (s F icial use only. Do riot write to tins area,to be completed by city or town official.y or Town: Perin it/License#. ing Authority(circle one): oard of Health 2. Building Department 3.City/Town Clerlc 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MM/DDJYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/06/2015 THIS IS 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(les)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 ondorsement(s), PRODUCER CONTACT Marsh USA Inc. NAME: 1560 SawgraI8 Corporate Pkwy,Aulle 300 PHONE Sunrise,FL 33323 (Aic,No, E-MAIL Atin!I 1[auderda1e.Cer1s@marsI),00rn ADDRESS: ------- NAIC# INSURER(S)AFFORDING COVERAGE 048953-ADT-GAW,15 16 INSURER A:ACE American insurance Company INSURED ---- -- 22667 AUT LLC -INSUREkB:Agri General Insurance CornpHny 42757 -- —----------- 18 Clinton Drive INSURER C:ACI'Fire Underwriters Co 20702 Hollis;NH 03049 _INSURER D INSURER E: COVERAGES CERTIFICATE NUMBER; ATL-003446293-04 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISFED 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 1-0 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERfAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES f.IMI'IS SHOWN MAY HAVF BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE F�Dafi- INSD��Vo ICY Err POLICY EXP POLICY NUMBER LIMIT S A COMMERCIAL GENERAL LIABILITY XIL GF111114 110/0112016 EACH OCCURRENCE $ 2,000,000 -DAMAGE I'D kENrE*9---- F MISFS - ccurnerce), 1,000,000 X 7 GLATMS-MADE SIR:$500,000 - - M D.EXP(Arlyonieper,on) PERSONAL&ADV INJURY 2,000,000 'GENL AGGREGATE LIMIT APPLES PER- GENERAL AGGREUA]E $ 4,000,000 X PCLIG1Y PRO LOG I JECT L I...PRODUCTS-COMP/OPAGG $ -,----4,C0O2-0OO 'OTHER _J s I AUTOMOBILE LIABILITY N-i -- S NIGI.F LIMIT A 0 ;111.1 LIMIT (Ea accide tL x ------- 4A ,' ANY BnD)LYIN,JURY(Pd,p.r.n) SCHEDOLE -E ALL OWNED D ' r AUTOG AUTOS BODILY INJURY(Per liscldnnt) $ 11IRLDA11101 PROPFRTY DAMACT.- I NON CIANI 1) (Per acciderd, HIRED AUT08 AUTC)S UNIFIRELLA IAAB R I' FACH OCC EXCESS LAD CL.AIMS:MAL)L: A(-',GRE(.,ATE D —J—f IENFON$11 -T-10N A AND E T3TS(AOS,) 1 0/2015 PL. 011i ,WORKERS COMPE 10,0 x I'TATLJ" IR- H MPLOYERS'ILIABILITY STA�TLJJF ER ANY FRCPRIL-IOIVPARThJFR'FXFC,[Jllll� YIN -411��332A(TN) 101011201S IC/01/2016 'IT CFI�CER�MFMEER EXCLUL)LI-, N N/A! F 1,FACH AGUIDELIT 2,000,DOD (Mandatory in NH) SG-F C4859333I("All) 10/0112015 110101i2016 I DISEASE-EA EMPLOYEE 2,D00,000 If yes,describe under ESCRIPTII-INOFOPLRATIOPdSt>tac,w E 1, DISEASE-'POLICY LIMIT $ 2,0D0,000 DESCRIP71ON OF OPERATIONS 7 LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached it more space Is required) Town of Nooli Andover Is Included as addlional Insured(excep(vxrkers cornpensirio-i),,0ive inquired by wettenconlract CERTIFICATE HOLDER CANCELLATION Town cf%frr Andover AI I f)�Electrical Inspector SHOULD ANY OF THE ABOVE DESCRIBED POIJCIES BE CANCELLED HEFORE 124',I�iin St THE rXPIFIA'riON DATE THEREOF, NOTICE WILL BE DELIVERED IN 1Icrlh Andover,MA 018,lb ACCORDANCE WITH THE POLICY PROVISIONS, AUTHOR17i'D R1 PREr ENTACPVF of Marsil USA Inc, Manashi rsluk-enee Nk"'-f—I (c)1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014101) The ACORD narile and logo are registered marks of ACORD