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Home My WebLink AboutWiring permit - Building Permit - 104 BLUE RIDGE ROAD 2/21/2013 Date�.. . ................ o�,«•� tio� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING '88�cr+use � U This certifies that .... .. ... ....�' �..k.... . � �� has permission to perform ...e. �... ., /�.4..... ._ ..... .. .a. ........................ ' wiring in the building of...,, ..,e� e� 3 at �. ��.. .... 3 t r orth Andover,Mass. Llb Fee.,_D................... � ..... B i;Ri CAL IN3PEcroR _ ® G Check# r pry`' ^fry a a_- f �e// Official Use Only Commonwea&of Mamaclwetb y 1 4 cc�� ec77 Permit No. Jl JJepartment o�,}ire�ervccee 7,0 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 TYPf\ZLLITO IO ) Date: ,� /City or Town of., To the Inspector of Wires: By this application the undersigned gives notice,of his or her intention to gform the electrical work described below. Location(Street&Nu I i J� j Owner or Tenant D Telephone No. - b j- Owner's Address Lam E Is this permit in conjunction with a building permit? Yes ❑ No ❑ (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: Completion of the following 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 No.of Luminaires Swimming Pool Above ❑ In ❑ o.o U cy Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 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 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❑ Municipal ❑ Other Connection Heating Appliances Security Systems: No.of Dryers g pp KW No.of Devices or Equivalent No.of Water Kam, No.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 OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: L )_ (When required by municipal policy.) Work to Start: 12j 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 ❑x 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. LIC.NO.: 7024C Licensee: Paul Delsignor Signature LIC.NO.:7024C (If applicable, enter "exempt"in the license number line.) Bus.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. 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 ❑owner's agent. Owner/Agent Signature Telephone No. IT : $PERM FEE _._,.._. ._ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r, I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Nightwatch Protection,Inc. Address:50 A Northwestern Drive Suite 9 City/State/Zip:Salem, NH 03079 Phone #:888-722-9282 Are you an employer?Check the appropriate box: Type of project(required): 1.[✓ I am a employer with 13 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' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I`am officers have exercised their a homeowner doing all work 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 13.� OtherSec.Syst-Low Voltage employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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. Iam an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name:Hartford Insurance Co.of the Midwest Policy#or Self-ins. Lic. 4:76 WEG JW2486 Expiration Date:12/10/2013 Job Site Address: �lJ' R-1Ac, LcQ— City/State/Zip: (A , Q Attach a copy of the workers' compensation p cy 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 pains and enalties o er'ur that the in ormation provided above is true and correct, Si nature: J Date: Phone#:888-722-9282 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#: