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EP-83236
,...rriI-..t, TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 8 3 2 3 6 ,-, - PHONE: 598-910-1820 , FAX: 508-910-1838 -y. - Name: L. C Property Owner: /- ..? , , .,_(,‘ \„patel.//6 1//- 7 2 77 s? z 16, ) Y Job Location: - ..? ....5( .e-, (it(c ‘,/ cc 4,J:1(1:Map: Lot: 7 0 6 0 Description General Ledger#'s Ref. # Amount Buitd.ing,&Puilding Misc. 01000-44105 I ,..---------, , electrical 01000-44106 .1 KT ,./ ,-,\ .5.\ A 7 2)- Plumbing & Gas 01000-44107 1 Trench Safety 01000-44129 't, , 6 , Other Department Revenue 01000-42420 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received -- THIS IS NOT A PERMIT/LICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS r - J L! �''J y J% . % C om.manw lecthh oil masdachadeal r"Official Use.Only (� 1,4 I 1 « r l :1Jeioarfinenit o��ire Serviced Permit i' . e 2' 3 �`" C BOARD OF FIRE PREVENTION REGU TIONS [Rev.Occ /o7jancy and Fee Checked 'Ji� (leave blank) tn'1 0, APPLICATION FOR PERMIT TO P FO ELECTRICAL WORK 24.1 All work to be performed in accordance with the Y[assachus - ical Code ME ..527 MR 12.00 AU./ (PLEASE PRNT LV L/K OR TYPE ALL INFOR1L ITIO:V Date: w�j j 6 q0 City or Town of: nr,r-(i^v;r-,, )t 1-\ To the Inspector f Wires: - a i 7 q By this application the undersigned gives notice of his or her intention to erform the electrical work described below. -11 f�cr f tiLocation(Street& Number) ad S ^ l ,6C r. Q., Owner or Tenant pc-1 l/1 d tilt icul C<<-, Telephone No.3C`; I 7 5 - N'Y Owner's Address Is this permit in conjunction with a building permit? Yes _ No (Check Appropriate Box) Purpose of Building N c 0.4`= Utility Authorization No. Existing Service Amps. / Volts Overhead 1 I Undgrd n No.of Meters New Service Amps / Volts Overhead_ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: c:-'c, oh -1Q 5� -i(V) LI J Cc Cie._Completion of the following table may.be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Traa onof T Transformers Ii�'VA A No. of Luminaire Outlets No.of Hot Tubs _Generators. K?A No. of Luminaires Above In- No. of r.mergency Lighting Swimming Pool arnd. ❑ grnd. ❑ Battery Units . No. of Receptacle Outlets No.of Oil Burners f FIRE ALARMS No. of Zones 3 • No. of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Total No. of Alerting Devices Tons s No. of Waste Disposers Heat Pump Number Tons__�KW. _ No.of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ iMunicipalLirlOther Connection • No. of Dryers Heating Appliances KW Security Systems:' .- No. of WaterNo.of Devices or Equivalent . RtiV. iNo. of No.. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent TOTHE R: ,r Attach additional detail if desired or as required by the Inspector of Wires.Estimated Value of Eh rical Work: I v C' (When required by municipal policy.) Work to Start: 1 C.:, y / % Inspections to be requested in accordance with itilEC Rule 10,and upon completion. INSURANCE 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. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. • CHECK ONE: NSURANCE ❑ BOND ❑ OTHER E (Specify:)Se/-' s0r-Qd I certify,under the pains and penalties of perjury, that the information on this application is true and complete. FIRyI NAME: A.1)T L.Z. C. D e p A_Di Secur{1- LIC. NO.: C- 1 7,I Licensee: i _ezz q J/i Signat re "/ iii :::::7 LIC. NO.:C-- 1 7 a, - (Ifapplicable.enter "exempt"in the lice a number line 1 —�� Bus.Tel.No.:`lV'35'S-sal Address: N 1 o I. n i -ens - e, 1J2s 0d M.A 01090 7 Alt.Tel.No.:IV-AS'5- C,S'Go 1 ;�, *Per M.G.L.C. I47,s. 57-61,security work requires Department of Public Safety"S" License: Lic.No. C0177 q ' J l 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, [hereby waive this requirement. I am the(check one)❑ owner q ❑owner's agent. r'• p fir' Owner/Agent ;! j ;�J Signature Telephone No. PERMIT FEE: R,t' lk."( ll s Department of Industrial Accidents --� Office of Jnvestia ation s sue_ F 600 liisliingioiI Street , Boston MA 02111 w141H?:mass.a o v/dia Workers' Compensation lnsura A '.idavit:. ui m/t ectors/l lectricians/Plumbers Applicant l� securi erVlc nn t Information � Please Print Le�lbly Marne 410 University Ave {f usiness'organirationlindividul): Westwoo©, MA02090 Address: City/State/Zip: Phone.;: 'i Y t- 3 s a . ►q Are you an employer?Check the appropriate box: Type of project(required): i. I am a employer with ci 4. D I am a general contractor and 1 6. D New construction employees(full and/or part-time).* have hired the sub-contractors 2_❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no employees These sub-contractors have E. El Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. 11 We are a corporation and its - re.quired l officers have exercised.their 10.0 Electrical repairs of additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11..0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no. 12.0 Roof repairs insurance required_] t employees. [NO workers' con!).. insurance required.] 13.5 ther LIN/ t„\ *Any applicant that checks box tr must also fill our the section below showing Their workers'compensation policy information. t Homeowners who submit this afdavit indicating they an doing all work and then hire outside contractors must submit a nevr affidavit indicating such ntractors that check this box must attached an additional sheet showing the name of the sub-contsactor>and their worker'comp.policy information. I am an employer that is providing workers'compensation insurance for any employees. Below is the policy and job site information_ Insurance Company Name: A Gr A-ry,, sC G74 J:) C (1-: ),I'j Policy#or Self ins_Lic.ft: C),)[_., C. t-f 9 1 o 2 117 . Expiration Date: i b\ ( C 1 ( Ne--,r4 Job Site Address: a ja,, J� o,q tic R d City/State/Zip: (Dq f hype4 'fl Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead 1D the imposition of criminal penalties of a fine up to.S 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 S250.00 a day against the violatbr. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida h ,y certify under the p• s:and .- : s of that the information provided above is true and correct S-.au ature: Date: I o\31 11. Phone it: `7 ' i j Official use only. Do not write in this area,to be completed by thy or town official City or Town: Permit/License if _ Issuing Authority(circle one): 1.Board of Health 2-Building Department 1 City/Town Clerk 4_Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#/- - A�oDDATE(MMlDDlYYYY) 2 CERTIFICATE OF LIABILITY INSURANCE �09/28/2016 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. PPHO N 1560 Sawgrass Corporate Pkwy,Suite 300 IA/C.No.Extl: (A/C,No): Sunrise,FL 33323 E-MAIL Attn:FtLauderdale.Certs@marsh.com ADDRESS. INSURER(S)AFFORDING COVERAGE NAIC# 048953-ADT-GAW-16-17 INSURER A:ACE American Insurance Company 22667, INSURED INSURER B:Agri General Insurance Company 42757 The ADT Corporation ADT Security Services INSURER C:ACE Fire Underwriters Co 20702 1501 Yamato Rd. INSURER D: Boca Raton,FL 33431 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003442307-09 REVISION NUMBER:1 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 EFF POLICY EXP LTR TYPE OF INSURANCE N W SD SVD POLICY NUMBER IMM DDUBR Y/YYYYI (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY XSL G27858703 10/01/2016 10/01/2017 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR DAMAGE RENTED PREMISESO(Ea occurrence) $ 1,000,000 X SIR:$500,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 • GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 PRO POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ A AUTOMOBILE LIABIUTY ISA H09050991 10/01/2016 10/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WLR C49103347(AOS) 10/01/2016 10/01/2017 X STATUTE PER OTH- AND EMPLOYERS'LIABILITY Y/N WLR C49103359 10/01/2016 10/01/2017 ANY PROPRIETOR/PARTNER/EXECUTIVE (TN)) E.L.EACH ACCIDENT $ 2,000,000 C OFFICER/MEMBER EXCLUDED? N N/A SCF C49103360(WI) 10/01/2016 10/01/2017(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ADT LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:TOM LEE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 410 UNIVERSITY AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. WESTWOOD,MA 02090 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _ .t�uv k ..N4-*A.tr_rRc ct- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Tom Lee SS-001779 License Number: • ^ Status: Active Renewal Id: Profession: Regulated-Activity License Type: Security Systems S-License Applicant Number 724707 Issue Date: 05/16/2012 Sub Type: Date Last Renewal: 04/20/2016 Expiration Date: 05/16/2018 Commonwealth of Massachusetts Department of Public Safety License:S5-001779 Security Systems-S- �n§e h., Y- THOMAS J LEit 410 UNIVERS'lTY . r z WESTWOOD}CAA 121)90 .c� Expiration: Commissioner 05/16/2018 Employer:ADT Security Systems-S-License DPS Licensing information visit: WWW.MASS.GOV/DPS • • fgOOMMONWEALTH OF MASSA6HIISETTS.,0 DIVISION OF PROFESSIONALLICENSUREBOARD OF ::: • .. ELECTRICIANS •-r.s,'•• ISSUES TI-LE FOLLOWING LICENSE As A •"1.I;ii •REGISTERED SYSTEM CONTRACTOR so • • • • , ..:,.ti•LP:ADT;LLCE)15.A.Ar:45,SECURITY 1,11: r•'• . .;w•-; 410 uNtygkati AVE • • •-•-. * • • wESfo(565,•MA 02090-2311 17.2 • 01-..13113.,..71„,..„9f,E. .,._. .122173 : - ,. . • : ..... ..... •