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Home My WebLink AboutMiscellaneous - 135 NUTMEG LANE 4/30/2018 l�1 �1 Z _ _ Date..../... ... .... of koR7p °oma TOWN OF NORTH ANDOVER--- PERMIT FOR WIRING �SS�cHusE� This certifies that / " " ................................ has permission to perform .`' -S wiring in the building of........ft.. ../✓G. .................................................... � ` at.....<....3 ........11r'..! ..... ° .......... . ........ ,North/Andvei,MFee.S ,4..:..G. .. Lic.No.Zw..�IG.... .... ......... .�... ... . ......... � E�crrttc.�t, xspacroR } Check #I 10575 Cccom�monwealth o�cc7�aeanachu�etfa Official Use Only MM ��r ! aL.lePad.,d o1,}ire Services Permit No. Ao .5 75 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK I All work to be performed in accordance with the Massachusetts Electrical Code(MEC),577 rc2.00 (PLEASE PRINT IN INK OR TYPE ALL INFORV TION Date:-- City ate:City or Town of: �M&Xte( To the Insrector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) I 'j )U Owner or Tenant (;Ct 11 V c,- L-t n Telephone No. Owner's Address G%� Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) 1\ Purpose of Building 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: Install residential security system Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA r No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones `° No.of Switches No.of Gas Burners o.of Detection and initiating Devices No.of Ranges No.of Air Cond. Tans No.of Alerting Devices No.of Waste Disposers Heat Pum Number. Tons KW No.of Self-Contained Totals "' '" ��"�� Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑.Municipal Connection 11 Other No.of Dryers Heating Appliances KW Security Devisteces or E uivalent No.of Water No.of No.of Heaters KW Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing No.of Devices or E uivalent _ OTHER: Estimated Value of Electric Work: 3(400 Attach additional detail if desired,or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: j j Inspections to be requested in accordance with MEC Rule 10,and upon completion. t INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless i 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: INSURANCE E BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Nightwatch Protection, Inc. LIC.NO.: 7 0 2 4 C Licensee: Paul DelSignor SignatureF 41 IC.NO.: 7024C (If applicable,enter "exempt"in the license number line.) us.Tel.No.• 888-722-9282 Address: 22 Briarwood Drive, Westford, MA 01886 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. .SSC00000969 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ p The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information l 1 Please Print Legibly Name (Business/Organization/Individual): {�1 (/l9Gl�Ci 1 Ie-G- I Address: W CL A) k r1 Sfe 9 City/State/Zip: AJQ Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.1I am a employer with 1 -2) 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. [_] I am a sole proprietor or partner- - listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance. # 9. E]Building addition required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t C. 152, §1(4),and we have no employees. [No workers' 13.W Other rj comp.insurance required.] PLAJ *Any applicant that checks box#I 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 hive outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ha4-� rod Q f M 1 Policy#or Self-ins.Lic.#: It W E6 JWa`I$Pp Expiration Date: Ia IID II Job Site Address: tJ'17►lk City/State/Zip: AJWeC.kU,L� Attach a copy of the workers'compensatiQ 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 to the imposition of criminal penalties of 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi5under the pai s andpenalties ofperjury that the information provided /above is true and correct Si ature: Date: / / 15 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Fold,Then Detach Along All Perforations V EALTH OF MASS _ BOARD LECTRICIANS UE , EMS TYPE D - m -C Map D °fpi°teasiona 0 85.6028 � I. • EXPIRATidN DATE SERIAL,NO. Fold,Then Detach Along All Perforatl6ns dM AUTHORIZED Nightwatch Q 11 °EAUR Protection, Inc. 50A Northwestern Dr.,Suite 9 Salem,NH 03079 Kevin Gilli an 15 Holly St.,Suite 208 g Scarborough,ME 04074 President toll free(888)722-9282 x121 kg@nightwatchprotection.com www.nightwatchprotection.com i l • z. De arty .,ent ofi P,: li Safety n b 4 hburton PI eAm 1 'b Nuinber SS CO..: 00.0969 Expire 10130/20: _ . , �0t .� � �yr]'� • " x „}�.. 'rteµ l2 . PAULGNOR s� • —N�1 t' PO B0)(249. PR _.. , V✓$RT'GEWA M-A 02379 .Tr.nq 159:fl Keep top for°receipt and change 6f address notification. DPS-CA1 is 40M-Mos,bas. ,per T�e'�wm�iruv�w o�.,��eoar/�uaet73 DEPARTMENT OF PUBt:IG sAFETI( S'-i foanse Number: SyCO 00969 W P,612. ;,t.no :1:59.0 s- NALARM RAIL Dl$ts1(3N_� 4A•�'�r�ti f PO 66X +49 W BRIDGEWATEF3, NtiA X279 C� Commisslgner. pIGa AI GALLCENTER (888)34—7233 i