HomeMy WebLinkAboutMiscellaneous - 9 MORTON STREET 4/30/2018 (2)Date ......z:.�... .
This certifies that ..7 ..G°. J,�G,�G f-,` ; �C
has permission to perform ..
wiring in the building of ................`...................... .
at .. �.. %%i" . ........ 511 .... , North A Clover, S.
Fee ......... Lic. No7� .'(.. .
�/...
ELECTRICAL INSPECTOR
Check
} 11115
C
COMM0 uveah. o/ecVa,,ac1e1b
11eParfinsnE o/Jire Jervaea
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. Z/// j
Occupancy and Fee Checked
[Rev. 1/071 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 ALLFORMATIO Date: Z —
City or Town of: \Rr To the Inspecto' of Wi're's.'
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) C M or+r) I) (� +
Owner or Tenant 1A,.f
Owner's Address
Telephone,No.
I Is this permit in conjunction with a building permit? Yes ❑ No X❑ (Check Appropriate Box)
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
ramnletinn of the AlLnofne /nhlo mau ho wnivoa by the I.—m. of w"—.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
o. o ota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool ove ❑ n- . ❑
rnd. Zmd.
No. of Emergency Lighting
BatteEX Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. o etectson an
Initiating Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
eatump
Totals:
"-
ons
....."......_.....".
"-........
o. oSelf-Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ municipal❑ �
Connection
No. of Dryers
Heating Appliances KW
Security ystems-
No. of Devices or Equivalent,
No. of Water,
Heaters
o. o o. of
Si s Ballasts
Data Winn
Na of Devices or E nivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommumcationswin-ng:
No. of Devices or Equivalent
OTHER:
/,e1 Attach additional detail if desired or as required by the Inspector of Wires.
i1stimated Value of Electrical Work: (y) _ (When required by municipal policy.)
Work to Start: 17, Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO r GE: 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 Q BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete
FIRM NAME: Ni htwatch Protection Inc. In ft LIC. NO.: 7024C
Licensee: Paul Delsignor Signature LIC. NO.: 70240
Wapplicable, enter "exempt" in the license number line.)
Address: 22 Briarwood Drive. Westford, MA 01886 sus. Tel. No.:888-722-9282
Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. • SS -001696
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 0 owner's a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S
y 2�
h
4 -
L,
It
� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual) : !U t4 � W ?fAe4-6n. _1 n c
Address
H, UJ,6_
City/State/Zip: 0'T Phone#: 898- 7aa- 9 a82
Are you an employer? Check the appropriate box:
1.)4 I am an employer with _13
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]
5:0. 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 perm MGL
insurance required] t
c. 152, § 1(4), and we have no
employees. [no workers'
comp. insurance required.]
*My applicant that checks box #1 must also fill out the section below showing their workers' compensation pol
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. >�Other_3 cuf���
I Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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 most 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: I �f" QY '� (U ayl 5 C r, � h r_S
Policy # or Self -ins. Lic. #: C p_ �' ^� ) J y b
Job Site Address: --�— City/State/Zip:,z
Expiration Date: I
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the paijg and plu s of perjury that the information provided above is true and correct.
Print Name:
Date:
Phone #:
OJjrtcial 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 Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #•
BOARD
FA
TYPE
-C
85.6028
Commonwealth of Massachusetts
Department of Public Safety
ScrurifN 1"aent.- ti Liccmr
License: SS -001666
f�
PAUL DELSIGNbR22 BRLARW9—OD UV -
Westford M.M 018K. "" m
o
Expiration:
�
Commissioner
01/25/2014 !
Fold. Than natanh Alnno All peAer*Nnn-%
AL11THORIZEo Nightwatch
°FAQ Protection, Inc.
50A Northwestern Dr., Sufte 9
Salem, NH 03079
Kevin Gilli 8n 15 Holly St., Sufte 208
9 Scarborough, ME 04074
President toll free (888) 722-9282 x121
kg@nlghtwatchpmtection.com
www.nightwatchprotection.com
• �i
F/ VV,
location
No. r 3 NOV Dat"'-�
NO
3 1
�ORT� TO -W 'dRdNq§TH ANDOVER
p Certificate of Occupancy $
�• ; Building/Frame Permit Fee $
s�cMusEth Foundation Permit Fee $
Other Permit Fee/ $
Sewer Connection Fee $ a
Water Connection Fee $
TOTAL
Building Inspector
a r_
Div. Public Works
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(Type or Print) ,•,`,; .', •'� � h
NORTH ANDOVER ,Mass. , :/.�:4; •. ` Oates' •1� T
`Building Location 9 ,a✓, c,2 /Z 7-o t-)' i Permit r
-- .
Owners Name 1�
New '0 Renovation j] ' Replacement ( Plans Sylbmitted
FIXTURFS
(Print or Type) ,
Installing Company Name !��S� vm� I.,
Address 7 < i e oc
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Business Telephone ��� �3 2ty SS
Name of Licensed Plumber.-
Insurance
lumber:Insurance Coverage: Indicate the type of insurance coverage by checking the ,
appropriate box:
Liability insurance policy [__j Other type .of indemnity Bond ;
�r
Insurance Waiver: I, the undersigned, have been made aware -that the licensee QVjL"A.
1
this application does not have any one of the above three insurance cQYerag@S.
• Signature of ownerlagent of property Owner Agent. 0•,
I bmbl► cellifr list all of tic dclads and iofornralion 1 Iea•c wLmilicd (at cntncd) is alwr`c application ata line 404 a/t to dw besl M a
k"wledge and tial all plumbing work and installations Ircr(nrmcd undcr rcrniil lrsucd for this appli slioo will be in baapWllp Pala ay pgdo"!p ill
WAG" of lbs Mawcbwolls State f lumbiot Codc and C aplct 142 of Itic (:conal la«s. 41
Title•(Signature of•'Licensed Plumber
City/Town: Type of Plumbing License.
A I�faRrlVFr) 7t]FFI(E USE ONLYI License Number ❑ Master 1❑�iaourneylt
Check one: Certificate '
❑ Corp -77..
❑ .-
Partner.
Cj Firm/Co.
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SUB—nBSMT.
BASEMENT
1ST FLOOR
R
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
'
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type) ,
Installing Company Name !��S� vm� I.,
Address 7 < i e oc
r9 -
Business Telephone ��� �3 2ty SS
Name of Licensed Plumber.-
Insurance
lumber:Insurance Coverage: Indicate the type of insurance coverage by checking the ,
appropriate box:
Liability insurance policy [__j Other type .of indemnity Bond ;
�r
Insurance Waiver: I, the undersigned, have been made aware -that the licensee QVjL"A.
1
this application does not have any one of the above three insurance cQYerag@S.
• Signature of ownerlagent of property Owner Agent. 0•,
I bmbl► cellifr list all of tic dclads and iofornralion 1 Iea•c wLmilicd (at cntncd) is alwr`c application ata line 404 a/t to dw besl M a
k"wledge and tial all plumbing work and installations Ircr(nrmcd undcr rcrniil lrsucd for this appli slioo will be in baapWllp Pala ay pgdo"!p ill
WAG" of lbs Mawcbwolls State f lumbiot Codc and C aplct 142 of Itic (:conal la«s. 41
Title•(Signature of•'Licensed Plumber
City/Town: Type of Plumbing License.
A I�faRrlVFr) 7t]FFI(E USE ONLYI License Number ❑ Master 1❑�iaourneylt
Check one: Certificate '
❑ Corp -77..
❑ .-
Partner.
Cj Firm/Co.
16
Date
T
EE
kORT
0
TOWN OF NORTH ANDOVER
CU
PERMIT FOR PLUMBING
T.D
SSACH S
This certifies. tha
.............
has permission to:perfo'r;n .......................
CU
plumbing in the buildings of
at.. . ......... North Andover, Mass.
't:;v .....................
Fet-,,?) . . Lic. Nd—A�? 71 .. .............
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer