HomeMy WebLinkAboutWire Permit - Permits #13295 - 12 NANTUCKET DRIVE 5/8/2015 - - \
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LIPmit Nc. aBOARD OF FIRE PREVENTI(JN REGUL — cupancy and Fee Checked
A I IONS 1/07 1 (leave blank)
AP PLICATI"ON FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(lvMQ 527 CMR 12.00
(PLE_ISE'PRINT IN.WK OR TEPE ALL,INFOld TIOh) Date:
City or Town of: _ To the hispector of Wires:
By this, the undersigned gives notice ofhis or her intention to perform the electrical'Work described below.
Location (Street&Number)
Owner or Tenant
Telephone No
Owner's Address M*;
Is this permit in conjunction with a building permit? Yes
❑ No 7 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
.Existing Service Amps / Volts Overhead ❑ Undgrd
❑ No. of Meters
New Service Amps / Volts Overhead ❑ IJnd rd
g ❑ No. of Meters
Number of Feeders and Ampacio,
Location and Nature of Proposed Electrical Worlc: e
Corn letian of the Jnllomrn !able map be waived by the L7spector of T�lires.
No. of Recessed Luminaires No. of Ceil.-Susp.(Paddle)Fans N0' °f Total
Transformers IOVA
No.of Luminaire Outlets No, of Hot Tubs Genemtors KVA
Na.ofLunrinaires Swimming Pool Above ❑ In- ❑ o• o innergency rgnrtng
„ rnd. „rnd,No. of Receptacle Outlets Batte Units
No, of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No, of Gas Burners No.of Detection and
Ina Devices
No.of Ranges ot2INo. of Air Cond. Tons! lNo. of Alerting Devices
No.of Waste Disposers Heat Pump )Number ons IOW a. of Self-Contained
Totals: _.. o
Detection/Alerting Devices
No.ofbishwaslrers Space/Area Heating IOW Local❑ Municipal ® O Connection thPr
No.of Dryers Heating Appliances I{y�, Security Systems:,
No. of rater No of No.of Devices or Eauival nt
Ballasts Heaters IOW a as Data Wiring:
Simms Balts No.of Devices or Eauivalent
No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Estimated Value afElectriaal WorJc
7 Attach additional detail if desired,or as required by the Inspector of Tdrires.
(When required by municipal policy.)
Worrkk t to Start;NCE COVERAGE: Inspections to be requested in accordance with MEC Rule 10, and upon completion,
o Unless waived by the.owner-,no permit far the performance of electrical worlc may issue nless
u
the licensee provides proof of liability insurance including"completed coverage or its substantial equivalent. The
pleted operation"
undersigned dertifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER U (Specify:) Gle-�� i c�
I certify,.under the pains and penalties of perjury,that the information an this application is true and complete." j
FIRMNAME: z1DT LLC DBA ADT Security
LIC.NO.: C-172 I
Licensee: Thomas j. Lee j
Sign1,16re / _ /�,...-.' ..--:_.-.- LIC.NO.: C-172
'�Address: c
Ifapplicable,enter "exemgt" 77 117E license number line.) Bus. Tel.No, ti p
�� UCO 1 � ��.0 Alt.Tel.No..%-'
*Per M.G.L.c. 147,s.S -G 1,security warx requires xdment ofPublic Safety«
S"License: Lic,No. .SS dU 1 779
OWNER'S INSURANCE WAIVER: I am.aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's a Ent,
Owner/Agent
Signature Telephone No, PE-R-41IT FEE:
jr
pie
Department of 111dustrialAceldelI&
office of-Investiptions
ri b 600 WashiligtOn SiFeet
Boston,MA 02111
VWjv.m rise go-v1dia �ectricjansffllumbers
WorlKers, corlape."Sation Insurance Affidavit: BuilderSICOntr actors'E' Tileg.9 Lrjut Legibl y
Nai'Ac(Businossiorganizationjindi-yid-,Tul)�
Address:
'Phone 4:
.city/State/Zip:
Are you a a employer?Check the appropriate box: Type of PrOject(required):
IA-Iama'employarwitll VOG(H�_ 4. ❑ 1 am a general contract-or and I 6, F1 Now c011structiOD-
have hired the sub-contractors
s
employees(full and/or part-time).* listed on the attached sheet. 7. r]Remodeling
2.0 1 am a sole proprietor or partner- These sub-contractors have, S. E]Demolition
ship and have no employees workers, comp.insurance. 9, F1 Building addition
working for me in any capacity. 5. E] We are a corporation and it . *epairs or additions
[No workers, comp.insurance officers have exercised their 10,El Electrical r
E] required.] right of exemption per MGL 11.E]Plumbing repairs or additions
3. 1 am a homeowner doing all work c.152,§1(4),and we have no 12J-1 Roof repairs
myself. [No workers'comp. employees. [No workers' Other \
e _-0
insurance required.]t eas. I 3
comp.insuranc,•required-]
Lwing their workers'compensation policy infoiMatiOn
plioant that checks box 41 must also fill out thc-section below shc
Any ai� work and then 11ija outside contractors must submit anew affidavit indicating such.
Hajjjeo�vnars who submit this affidavit indicating they are doing Ell WO sub con and their workers'WHIP,policy information.
lContractors that check this box must attached an additional sheet showing the name Of the 7
tlle.poliey andjob site
Insurance Company Name:
-caio -k Do ft7,
Policy#1 or Self-ins.Lie.9 ca t 0
City/Stat
C/Zipl �c�� — � C
Job SitcAdd.ress: ljowing the policy number and expiration date).
Attach a copy of the workers' CO-1upensation policy declaration page(s to the,imposition,of criminal penalties of a
Failure to secure coverage as required Linder section 25A of MOL c. 152 can lead
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORX ORDER and a fine
of up to$250.00 a day,against the violator. Be advised that a copy of this statement may be forwarded to the Office Of
Investigations of the DIA for insurance coverage verV:-afion.
t the information provided above is trace andeorreek.
cerfiry1inder thepainsIlyn ell.allyes of-pe1jary#101
\25
Si gnaaft kf Phone
Official Ilse Only. Do not wrile in this area,to be cornpleted by city or tow"dflelal
City or Town.
Issuing Authority(circle One):
.1. oars of Health 2.Building Depar'MeDt 3.City/Town Cierk 4.Electrical Inspector 5.Plumbing Inspector
B ,
6.Other
Phone 9:---
Contact Person-
" DATE(MM/DD/YYYY)
A IR" CERTIFICATE OF LIABILITY INSURANCE 1 p1 0812014
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 IJSA Inc. _NAME PHONE FAX -...... --
1560 Sawglass Corporate Pkwy,Suite 300 LAIC,No,Ext): _ (A/C,No)
Sunrise FL. 33323 ADDRESS.
Atin Ftl auderdale.Ceris@marsh.coni -
INS U 11 RER(S)AFFORDINGCOVERAGE _ _ NAIC_#
048953-ADT-6AW-14-15 NSURER A:Zurich American Insurance Company 116535
INSURED INSURER B Amercan Zurich Insurance Company 40142
ADT LLC -- ------
18 Clinton Drive
INSURER_C.,,..
Hollis,NH 03049 INSURER D:
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.
INSR �ADDL SUER --- POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MMIDD/YYYY
A GENERAL.LIABILITY SLO 5095869 02 1010112014 10I01/2015 EACH OCCURRENCE g 2,000 000
- CO_MMERCViL GENERAL L DAMAGC TO RENTED -_-
X - X (ABILITY I PREMISES(Ea,occurrence)_ $ 1 000,000
J CLAIMS-MADE CCCUR MED CXP(Any one person) S 10 000
PERSONAL&ACV INJURY S 2,000000
GENERAL AGGRPGATF S 4,000 000
{:EN L AGGREGATE LIMIT APPLIES PFft PRODUC IS-COMP/OP AGG $ - 4,000,p00
X PRO- I $
POLICY - T I I...00;
B AUTOMOBILE LIABILITY SAP 5095900 p2 ..1pI0172014 10101!'2015 Ca accdeMbINGLF LIMIT q 1000000
) __ -
X ANYAUTCJ HUUILY INJURY(Per person) $
ALL.OWNED SCHEDULED ', BODILY INJURY(Per aocidenq $
AUTOS AUTOS
-_- I NON-OWNED PROPERTY DAMAGE -- $
-. HIRED AUTOS AUTOS (E'er accident)......_ --. -_-. ......_
$
OC UMBREL.L.A LIAR EACH C)CCURRFNC,E _ $ _
( Irft i
EXCESS LIAEI a I MS MA F: AGGREGATE-. $ _....
_ DED .... RETENTIONS' .___. S
B WORKERS COMPENSATION WC 5095897 02(AOS) 1 10/0112014 10,101/2015 X WC STATU OTH
OFFICERIMEMB 5'LIABILITY WC 509589802 MA,CAI 10,01?2014 1.TORYIIMITS ER _ - _
A 0;0112015 7.000 000
AND dEM�LO�EORJPARTNPR/EXF.`.C'UTIVF E L_EAGH ACCIDENT S _
ANY PROPRIET
(Mandatory NH) L I C)ISCASC EA EMPLOYED S 2.000000
If C YeSr describe
ndor ERATIC�IS below PV .NIA F.I_.DISEASE-POLIL"Y LIMI I 5 2,000,000
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 rdntraal,.
v
CERTIFICATE HOLDER CANCELLATION
Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
A!IN Electrical Inspector THE EXPIRATION DATE THEREOF, NOTICE WILL BE. DELIVERED IN
V4 Main St ACCORDANCE WITH THE POLICY PROVISIONS.
NoWiA.ridovhr,MA 01845
AUTHORIZED REPRESENTA TIVE � ~
of Marsh USA Inc.
ManEashl Mukherjee
__...__....._.__.--_.._._............._.._._..__.. _ __. __ �_ __
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD