HomeMy WebLinkAboutWire Permit - Permits #11933 - 20 NANTUCKET DRIVE 10/15/2013 El
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APPLI r JIiIION FOP If"E Ai:Ur lE PE•RMRI ELECTRICALWORK
I
All wordin b a porljoimrdin accord an Co do(_M:7 C),527 : 12 0 N
uusEI'_Z?Z7VZ'1N'Ll�KO,'I2'�''�rJ T raR�l_�`i�ol7 late. I:t
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` By tH5 applicaioazh.e undersigned gives nolice of his or-barint-nuGir to periorra.tha ele06dcal W0l-IC describedbelMV.
. Loc�steorxx(Stz•eet�]_r7vm.Iter) ) ,✓" CSC` ����a., L,./��~ _ __ I:
Falepb.ancNo<ti - 'I
' ovruer-',s A ddress__„_.. -_ --- -- I•
i9 tSx s per z r_t in cons�zzaiion vt fIx a Urilding per n i? Ye,3 ❑ i Fa (Ch.ecir fz-Pproprfafr Boy)
rurpose ofB-Ti ldfng ULHty 2 uaMarizatloa Yo. I1
rq'zs- gSerVic< Amps 1 Vohs ovencc-al" Tlndgrd. - 'No.of Me{ers
Ne'wService Amps. l voffis Overhead Und d I'
P 0. �' � l�Ia4 ofl�efei',s
��iTiIl. er o�S:t`r'eders,axxdhna.rrar,Ei.•�r _ _ ____ ;� '
E ocaiion.arzd I aftare of Fra used x Tzzf cat nrk g� ` A
f` I
Cara�letion of ilze foltax>its Icrble nt be yJanred by the InspecEor of�rzres_ '
r�ro oTecn� �d-p_nnsrarres- b oiCell.=Suslx_ dclaras lto.oL Sofal -
___
rN11 :Ifl-I
LrIVY.Above7_u" - o.a.• a�mergy xg&at Ti"ngTlnms'_trar"res ISwinzmzngk000l grnd. �� d. � Batfe 0'nits ' .` I
t � ReesaelL}n=kIets—_._- _n £ f��er
b.of S7itchrs ia„of Gas Buxners fVa.of l7eteon as
I-uitiatin devices
No,of-Ranges -- No-Of fir Coacb - Tons Ada,of'Aierf_infy Devicas -----
_-_ Tdeatl'urap Nu_Er Tons ICW pNo.of If
l@o.af F5✓astIlisposers TofaL: 1 7efection/ASeledces
_ I`fSrzuiex at � i
No.ofJ-is€wasbers �Space(AxeaF3eatan� �' Tncat�} Copuec�con
i
Tv Heatitx�A fiances security Sps`�ems_•r_-..-- �----- ,
l b.ofl7xyers pls l�ro,of L?e�ric or.Fquiv_s.Ien
-No.of Water No.of No.o - La as�fiEin�:
_ Heaters �� I ms �allas� No,of7}evices ors u valent Si
Telecommurxicatxons Witixxg:
1�7b.Rydrora�sssageBatttrrbs ��"a.oi'Motors 'T`afi�s_t:Ell'' � I
Na.o.f.Ilevices or L uzvaieztt
1
r3>'i=-cl��c'di�ionaZdetnit if desirF:�oY as rey�irp-u`7�y fF?Ins ector of Y7irEs.
Est n aiecl Varue of E1ec ic�l V�orlc. J (Mam reg fired by municipal policy.)
Work to Start � In pections to Tce r�quaair.ci m aacordanr ,�viilrIEC l2i?la 10,and mpon cony rJeiioar
ICZSURA-NCB C£IVERAC.YU: Unlr ss wal nd,by the nvtnerx.no pcnjit for tho perfbron ce of el ca;9.cal v ar?c may issm"tbEcSs
fhe IicenSm pa`avzcdes proof m=liab> ty:sszu2nce inclnditig"courpie ed aperuon"coverage or rfs subs 1zA equivalm4 `Iho
um-larsipcd cey-�fes That sarh coverage is i a force,and has exluhite 1 proof.of sa oe to tho parm%t issue;;o[.ace,
CBBCK o?�: INSUx�ArCB I� J3ON17 I� CAR h (�peuy.) selfla- d
2 cPr#i J'T rcn i t the p¢ztt arxd penal a afpeal`ur77r th the frzlgu n ar an this dppZica io c zs lr rye and co z to e
SRIV ,r�1YJIlk DTLLCDBAADT,5emzity �1 � G?C,llo,. C-172
_ - r .�
ucensee: 'Thomas K ltic ignnat7xra � ff��-� LIC.l;r 0.: C-172
(Yapplzcable.ei tsr' `exempt"Lathe lace; •e number X:ne•) /_ _ Bus.TeL:Ko.:
/a
Address- e° �eirr /62 ,�� t d E�✓� `�tV�;rf Utz Tal
TSa ini y System CorzfraotorLiconsD required for this vrml_c;if appEcab?e;mt-ar the license n=6ar hera„ 001779
a l IMP'S SNSTT AI E P�If CVEI I am.av�are die Licensee does not have the 7iRWRI y in a nco cavera�o not aBIly
%� required by Iav✓, By my sr�;cfiirg below✓,T hecrby-„�iv�tI_�is zecjair emenr. I am the(check one)(�a�tno;. ❑avm�-'s a€;en�.
SS1vP er/Bent '
us{ .aGax� �_ peleplzozzU tTrs, s 1" I,*. .a�71 /" �
Tke Canunonweaffis of Massachusetts
Departownt of Industrial A ccident.T
Dyke a��'1"rrt�t�sti �tt��rt�
jt00 Wash thgttrtr Sheet
Workers" Compensation Insurance Affidavit: i t°s/ wat tray srs/Electri rt / hi rin hers,
li aaji Inform:!titan Please Print Lc, ibLv
DT Sit Services
Name ecury � . ....,_ ,_._.
Address- 18 Clinton Drive
City/State/ ily Hollis NH 03049 PhoneAre you«pan employer: Check the appropriate box Type of project(required):.
1, 1 aura. employer z with ........ ._ + 4. [] l arat to ivncra9 corttractor and 1
0 ___ t5. ( 1 a:ryatrxtttrc tir�n
emplox�eC (ball a-mil sz Part-time),*
cior
have hired the tiCt�� Jttttit
tt� racta�ra�r���rts�r- h 7. �l� rin�» e3ia�i;
. 1 aart as sole F` fa � li�ta�d twat ���tt�tcitcal sltcct.
ship and ltt�"e rapla�'aes litc�sc"�td�r�e���traCt�rs�awt; � �t� a�lititan
�«orkirtg ftir true tit and.capatcity, cttrplt.ins titan �l.- workers' 9. Building addition
I�lo works rs'comp-insurance comp.a insurance.-
t��ttircrl.
�'U`a ttrc a ctyrpatratrrtt urtr9 its tl)Fl tla✓etria;atl repairs t�tr adtlitirrt�,
3„ 1 a r homeowner r dtrira all work, offlic rs have exercised their 11.E]t'lu3xabing repaii-srar additions
myself` [No workers' cottap. right�afc�criapkic�raperlvltal� i2;, Roof repairs
iatsursancercquired,] 1w2, lt4l,Arad a h veartl I I.Co other Low Voltage
comp,insurance,required.1 Security System
"Any applicaant 1ha.t ui k%bO.q#1 uw5fmjjn rill out the scvtiDn below sbuwing their w oci ers'ct iiipcn Lion pniicy"intonn-otion.
t Homeowners Who Sukrrrut this africtcvit indicaating,they are afoimg all wtka acid then hire oulsW contraactnrr,mast subrnit a now affidavit Wicaling surf
antractorst that check this box mast,thatched an addiiifstanl sncect showing the a inc of the sutrccrnlracttrri and suitz vatcrther or not thosc amities have
cmployfa , k(the.sub-contratctors have crnploy°e s.they must pttti idc their wortcrw"conch.policy murnbcr.
lam an employer that ls prcrrltiing workers'cantlaernsation `murrancefor my earttployee,a'. Below is site policy and job site
l4formation.
Insurance Company Name. Zurich American„Insurance Co.
Policy#rrr Self-ins,Lic.fr; WC509589701IWC509589801 Iixpiration Date; 10/01/2014
job Site,Artdt° ss:& �i�,r�.�� Cityt-statct' ip
Attach a copy oft The workers'compensation policy declaration page(showing the policy number hard x tration dale).
Failure to se-Ou e eovertrge as required under$ tion 25A of l 16L c. 152 can lead to the impcss tirrn of criminal penalties tat a
tine up to$1,500,00 and/or one-rear irttpri:ttrtttttent,as well as civil penalties in the form of a P 4at±'ORK ORDEM and a fine
of lip to$250.00 a day 4 Taiztst thL violaator. '1 o;advised that a copy of this statement may be t'ctrward l to the Of icc of
Inv ligatic)ns.atf the DIA for insarrance caaverago.vcrijtcation.
. .. - s race rt
l'da hereby ee l° nder the pains a nd perrrr.hiev ofperjury t axt the information pray Weil arlrue°a i t rl correct.
lrh rt t: 603-594-5937____---
0jt,�"reiatl ruse only. o not write in this area,to he eonwleteod by eity=ortr wn,officitti'_
City ties^fro w". _ 9Pt rrttitlt,ica rt+te _._�
Issuing Authority(circle erne).
1.13naard ofTUt jlttt 2,Ruittling Department 3.t'ityfl'o n Clerk 41,Electrical Inspector 5.1Plumbin Inspector
.Other
Contact Person: Phone 9.
DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 09I25,2013
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 w
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT 'a
_NAME:
ADD Risk Services Northeast, Inc. PHONNd.Ext): (866) 283-7122 (A/C.No.: (800) 363-0105 ar
Morristown N7 Office 'a
44 Whippany Road, Suite 220 E-MAIL =o
Morristown NJ 07960 USA ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIL#
INSURED INSURER A: Zurich American Ins CD 16535
ADT LL.0 INSURERB: AMe.rican Zurich Ins Co 40142
ADT Security Services
1.501 Yamat.o Rd INSURER C:
Boca Raton FL 33431.-4408 USA INSURER D:
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER:570051395419 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS 1 ED 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. Limits shown are as requested
INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MMIDD/YYYY POLICY Err POLICY EXP LIMITS
A GENFRAI...I...IABII..ITY GLO EACH OCCURRENCE $2,000,000
X COMMERCIAL GENERAL LIABILITY DA A N $]-,00O,OOO
PREMISES Ea occurrence
CLAIMS-MADE X OCCUR MED EXP(Any one person) $10,0OO
PERSONAL&ADV INJURY $2,000,000
GENERAL AGGREGATE $4,000,000
000 000 COMP/OP AGO $4, ,
GENE AGGREGATE LIMIT APPLIES PER. PRODUCTS- in
X POLICY PRO- LOC CD
ti
AUTOMOBILE LIABILITY CEa OMBac INED SINGLE LIMIT
cident � ..
ANY AUTO BODILY INJURY(Per person) �.......__ 0
ALL OWNED E SCHEDULED BODILY INJURY(Per accident) N
AUTOS AUTOS
NONOWNED PROPERTY DAMAGE
-
HIRED AUTOS (Per accident) w
AUTOS
d
UMBRELLA LIAB OCCUR EACH OCCURRENCE U
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTION
B WORKERS COMPENSATION AND wc509589701 10/01/2013 10/01/2014 X TORv lSMTs ERH
A EMPLOYERS'LIABILITY Y/N WC509589801 10/01/2013 10/01/201.4
ANY PROPRIETOR/PARTNER/EXECUTWE E.L.EACH ACCIDENT $2,000,000
OFFICEWMEMBER EXCLUDED, N I A
(Mandatory in NH) F_L.DISEASE-EA EMPLOYEE $2,000,000
It qes,describe under
DESCRIPTION OF OPERATIONS Below IFL..DISEASE POLICY LIMIT $2,000,000
WAL
e�
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
J�
-ILr
-S�
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE -
POLICY PROVISIONS.
TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE 1�7J
INSPECTOR. OF WIRES F=-
124 MAIN ST. yam'^ lie
NORTH ANDOVER MA 01845 USA C�� e4GBG$^!Yd'd t✓'Je9L' 53"rrry e../
@1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD