The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 35 MAGNOLIA DRIVE 4/30/2018I Date ... ... �gm, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... n .................................. . ................................. has permission to perform........ ................................ wiring in the building of .......... .................................................... 3 at ........5. % . ......... . 4 .... ..... ,North Andover, Mass Fee. -5-5 .......... Lic. No. �� ....... . ...... . ..... `ELEcmcAL INsPEMR Check # 105.69 Commonwealth of /'{'lamackueeffs Official Use Only 2epadfineni of ire Service., Permit No. l G ✓� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR44 TION) Date: az/9 /// City or Town of: (yrr To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) _ 3 ,a Ston e i 'Q- D `. Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. Yes ❑ No ® (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install residential security system Cmm�lotimmn/YAor71.,... ;--#-I,/„... .L,.. ".,7L...L_i______._ _>•a>• No. of Recessed Luminaires --••• • -•-�•• .••� ........... No. of Ceil.-Susp. (Paddle) Fans .uvw n.0 c rvutvcu u �i�u lw eciur u Wires. No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. nd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Deterflo—n and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alertin Devices g No. of Waste Disposers Heat Pump Totals: Number Tons "'"'" ' '' KW """""""" No. o Sel -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of of Bal Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Euivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _ V (When required by municipal policy.) Work to Start: ` Inspections to be requested in accordance with MEC 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: INSURANCE ® 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. _ ,r1 LIC. NO.: 7 0 2 4 C Licensee: Paul DelSignor Signature 1, AA - X AX =& ]C. 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. $55. ce) INA The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City Phone #: 9 Are you an employer? Check the appropriate box: 1.11 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time)..* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- - listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance,$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp.. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.W Other,0jjC fl J Soso ow *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. V t Homeowners who submit this affidavit indicating they are doing all work and then hire 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. , , I , Insurance Company Name: -r[& �-rTo r Policy # or Self -ins. Lic. #: 7�Q W �(T J wa `� $(,p Expiration Date: Id Job Site Address: J �Aac�oo�A `�r , City/State/Zip: A 6 ( b 5— 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 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 certify under the pauq and penalties of perjury that the information provided above is true and correct. Signature: Date: N 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 #: BOARD FA TYPE -C 85.6028 Fold. Than Daterh Ain— All Parfr; nfl na AUTHORIZED DEALER Nightwatch Protection, Inc. 50A Northwestern Dr., Suite 9 Salem, NH 03079 Kevin Gilli an g 15 Holly St., Suite 208 Scarborough, ME 04074 President toll free (888) 722-9282 x121 kg@nightwatchprotection.com www.nightwatchprotection.com Dec 16 2818 111229 EST FROM; FZM/31013588573 FOR: MSG# 18909138-887-1 SUMMARY OF INSURANCE NIGHTWATCA PROTECTION INC 50 NORT "STERN DR # A UNIT 9 SALEM NK 03079 Phone; (603)685-0240 BY: HOME OFFICE AUTOMATIC DATA PROCESSING INS AGCY PO BOX 33015 SAN ANTONIO TX 78265 Phone: (877)287-1316 ACCOUNT POLICY RECAP Policy Number Workers' Compeneation 76 WEG JW2466 Hartford Ina Co of the Midwest Policy states: ME MA NH Lo'gticn 01 Pramireog Addrean 15. HOLLY ST SCARBOROUGH ME, 04074 Location 02 Pramises Address 22 BRIARWOOD DR WESTFORD MA, 01866 Location 03 Premlees Addrees 50 A NORTHWESTERN DR UNIT 9 SALEM NH, 03079 PAGE 88Z OF 99Z TkE it EiiTF ORD Prepared: 12-16-2010 VAX; (603)685-0244 250717 VAX: (888)443-6112 Eff Date EXP Date Prem 12102010 12102011 $6,873,00 worker's Compensation CoVeraCea Employer's Liability Limits Limit Disease - Policy Limit $500,000 Disease - Each Employee $100,000 Each Accident 0100,000 IAdividual Included/Excluded Class/Payroll Detail Class Description C18742Code Location 01 - ME SALESPERSONS OR COLLECTORS oll Location Location 02 - MA - 0 FIRE ALARM, TELEPHONE OR TELEG 7601 $61, $61,900 900 Location 03 - 03 NH BURGLAR ALARM INSTALLATION OR 7605 $77,600 Location - 03 - NH NH SALESPERSONS OR COLLECTORS - 0 8742 $41,400 CLERICAL OFFICE EMPLOYEES NOC 8810 $141,600 of Em This Summary and its attachments provides a high level overview of policy coverages and does not include all conditions, limitations or exclusions, Please refer to the actual Policy forms for detailed coverages, limits and deductibles, ate.. A..�P. ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.�.!..• .......... . has permission for gas in`�tallation....... in the buildings of . .... �. ................. at ►- ! . `....... . , North A_ . Andover, Mass. Fee L. No. . ......... �� GAS INS: Check ## 5294 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAWITTING (Print or Type) 00ff-�%��)� �_, Mass. Date _ OJ Permit # q � a Building Location__ 3 J "(Y rWL.iA D2 Owner's Name HALL L,A i3 LLF - QORTN A 1G)\f6R. Type of Occupancy RES) 0,e -AJ -r1 A L. New ❑ Renovation ❑ Replacement] Plans Submitted: Yes❑ No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone q 7!B-68.7-1105 Name of Ucensed Plumber or Gas Fitter Francis X. Corkery Check one: �❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy X( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's lowner[] Agent ❑�gent , 1 hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accur to to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of License: Plumber Signature of cense lumber or Gas ask Title Gasfitter Master License Number City/Town Journeyman IIF'PROVED (OFFICE USE O ■rrrArrrrrrrrr■ rmom 0 NNN rrrr;�rrr■rrrrrrrrrtrrrrrrr� ... ■rrr�rrrrrrrrrrrrrrrrr.rrr■ • .. ■rrrrrrrrrrrrrrrr rrrrr■ rrr .. ... rrrrrrrrrrrrrrrrrrrrrrrrrr■ .. • ■rrrrrrrrrrrrrrrrrrrrrrrr■ l • • ■rrrrrrrrrrrrrrrrr ■r■ rr■ • • • ■rrrrrrrrrrrrrrrr■ rr■ rrr .. ■rrrrrrrrrrrrrrrrrrrrrrrr■ .. • ■rrrrrrrrrrrrrrrrrrrrrrrr■ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone q 7!B-68.7-1105 Name of Ucensed Plumber or Gas Fitter Francis X. Corkery Check one: �❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy X( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's lowner[] Agent ❑�gent , 1 hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accur to to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of License: Plumber Signature of cense lumber or Gas ask Title Gasfitter Master License Number City/Town Journeyman IIF'PROVED (OFFICE USE O Z O_ N U w Ix N Z N N w cr 0 O a M NI w z UI F - w �C N I JI O z d J t CI zP 1 - LL N J 0 Z O O a w N O � ~ W. U k • a o a 0 z a a O O IL �- � Z o 0 J F w a m V J a a a w w &L NI w z UI F - w �C N I JI O z d J t