The URL can be used to link to this page

Home My WebLink AboutWiring permit - Correspondence - 691 GREAT POND ROAD 9/22/2014 (3) Date k? k J ;P�...•...... F tiO3�••' -.: :�. oo� 7,®dry/ NO N OF RTH ER ANDOV * _ PERMIT FOR WIRING ��,CHUS�4 This certifies that t „ ......� .. a .. has permission to perform .• .... r NN ,gg� wiring in the Wilding " " ""' at ��_ �� 6 Fee � .� ....... .........,North Andover C �� g . ,Mass. Check# `� `{ ELECTRICAL INSPECTOR...................... , '=— C o nwe atlCa.of Official Use Only CIA � Permit No.Occupanc BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07]y and Fee Checked leave blank APPUCATEON FOR PERMET TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Co�dee�(r�5� CMR 12.00 (PLEASE PRINT IN INK O TYPE ALL INFORMATION) Date: -�i q City or Town of- d yt1 To the Inspector of Wires.- By this application the undersigned gives notice of his or her intention to orm the electrical work described below. Location(Street&Number) ``,n, Owner or Tenant ��Sa y ( C Owner's address �l Telephone No. — — 53 U Is this permit in conjunction with a building permit? Yes ❑ No Check Appropriate PPropriate 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: tt50�� eS Aden}� �t fCUYi�� '(S '1 a Completion of the following table be waived by the Inspector of Wires. No.of Recessed Luminaires N&of Ceil:Susp.(Paddle)Fans °•of Total Transformers KVA No.of Luminaire Outlets No.of hot Tubs Generators KVA No.of Luminaires Swimming Pool above ❑ In- ❑ o.o mergency tg ng rnd. rnd. BRYM Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of-Gas Burners o.o OtR Initiating Devices etechon an No.of Ranges No.of air Cond. Too No.of alerting Devices No.of Waste Disposers eat ump ...um...er Tons ...._. __ o,o S -Contain Totals: .............""'" 'Detection/AlertingDevices No.of Dishwashers S ace/Area Heating Municipal P g Local❑Connection [I Other IN&of Dryers heating Appliances uriNo. f Devices or li;auiyalen!t Systemn o.o Heaters iVerNo.o ®•o Data Wiring: Signs Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin No.of Devices or E uivalent OTHER: ( I Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: `1 c)(J- (When required by municipal policy.) Work to Start: C1 )F)I I qInspections 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 andpenallies ofperjury,that the information on this application is true and complete FIRM NAME: Ni htwatch Protection Inc. LIC.NO.: 7024C Licensee: Paul Delsignor Signature A4� LIC.NO.:7024C (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.•888-722-9282 Address: 22 I3riarwood 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 a ent. Owner/agent Signature Telephone No. �� tTtT FEE: $ 5�j I ) H VZ-e 0-91 �ul MAI . —purrrr¢s raa Uy ltre&UNfrlalACCiaents a Office of In vestigations I Congress,Street, Suite 100 Boston, MA 02114-2017 ww .ratass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print LUibly Name (Business/Organization/Individual): Nightwatch Protection, Inc. Address: 50 A Northwestern Dr. Suite 9 City/State/Zip- Salem, NH 03079 Phone #: 888-722-9282 Are you an employer? Check the appropriate box: Type off 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' insurance.$ 9• ❑Building addition comp.[No workers' comp. insurance p• required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions g officers have exercised their ❑ 3. I am a homeowner Join 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.E other Sec.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. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ►ployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. me an employer that isproviding workers'coonpensation insearance for nay employees Below is thepolicy andjob site formation. ;urance Company Name: Hartford Insurance Co. of the Midwest licy#or Self-ins. Lic. "#: 76 WEG EV7027 Expiration Date: 12/10/2..014 �4,Site Address- k � City/State/Zip:� _ gym_r MQ o j tach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby ce fy sander the Pains and penalties of perja y that the information provided above is true and correct iature: 4 W i' -g'' Date: g ljq f icial use only. Do not write in this area,to be completed by city or town official, ity or Town: Permit/License# suing Authority(circle one): Board of Health 2. building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector Other Dntact Iverson: Phone#: Nightwatch Protection, inc. 50A Northwestern Dr.,Suite 9 Salem, NH 03079 Kevfn �� 15 Holly St.,Suite 208 Scarborough,ME 04074 President toll tree(888)722-9282 x121 kg@nightwatchprotection.com www.nightwatchprotection.com Commonwealth of Massachusetts Department of Public Safety Security Systems-S-License License: S-001696 PAUL DELSIG - � y.,.. . 22 S R'®Q�IlB - Westford VA VI z Commissioner Expiration: 01/25/2016 Fold,Then Detach Along Alt Perforations ��.tttJ rl.�n F .;. �•'i . � � !t EL."s�"�ICIANTS ISSUES THE. FOLLOWING L I C'l+NiSE AS A RED 1 STERED SYSTEM CONTRACTOR Ni1GMATCH PROTECTION INC PA'UL J DE.LSMM 22 BRIARbdND DRIVE WEITFORD MA w 886-i i 65 7024 C 07/31/16 50372 SMOCARY OF INSURANCE ffiE RTFORD FOR: NIGHTNATCH PROTECTION INC Prepared:12/10/2013 50 NORTHWESTERN DR # A UNIT 9 SALEM NH 03079 Phone: FAX: BY: HOME OFFICE PAYCHEX INSURANCE AGENCY INC 210705 PO BOX 33015 SAN ANTONIO TX 78265 Phone: FAX: (868) 443-6112 ACCOUNT POLICY RECAP Polic N r Eff Date E Date Premium Workers' Compensation 76 WEG EV7027 12102013 12102014 Hartford Underwriters Ins Co POLICY DETAIL Policy Workers' Compensation Policy States: ME MA NH Location 02 Premises Address 15 HOLLY ST SCARBOROUGH, ME 04074 Location 02 Premises Address 22 BRIARWOOD DR WESTFORD, MA 01886 Location 03 Premises Address 50 NORTHWESTERN DR• # A UNIT 9 SALEM, NH 03079 Worker's Compensation Coverages pnel2yerls Liability Limits Limit Disease - Policy Limit $500,000 Disease - Each Employee $100,000 Each Accident $100,000 Individual Included/Excluded Class/Payroll Detail Class Description Class code Pa rollo£ Location 01 - ME SALESPERSONS OR COLLECTORS - 8742 $56,243 Location 02 - MA FIRE ALARM, TELEPHONE OR 7601 $80,189 Location 02 - MA SALESPERSONS, COLLECTORS OR 8742 $36,329 Location 03 - NH AUDIO OR INTERCOMMUNICATION 7605 $117, 134 Location 03 - NH SALESPERSONS OR COLLECTORS - 8742 $48,580 Location 03 - NH CLERICAL OFFICE EMPLOYEES NOC 8810 $312, 969 'his summary and its attachments provides high level overview of policy coverages and does of include all conditions, limitation or exclusion. Please refer to the actual policy orms for detailed coverages, limits and deductibles. 1 ® DATE(MM/DD/YYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 10/10/2013 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 Beecher Carlson Insurance Agency, LLC CONTACT NAME: Beecher Carlson Insurance A ency.LLC 1700 Hudson St., Suite 204 PHONE No,Ex FAX A/C No: 503-274-0323 Longview, WA 98632 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# www.beechercarlson.com INSURER A: Great Midwest Insurance Company INSURED INSURER B: Great Midwest Insr ance Company Nightwatch Protection Inc 50-A Northwestern Drive Suite A INSURER C Salem NH 03079 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 18016506 REVISION NUMBER: 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. ILTR ADDL SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MM/DD/YYYY A GENERAL LIABILITY PP00036987-01 9/28/2013 9/28/2014 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE O(Ea occurrence) $ 100,000 CLAIMS-MADE �✓ OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) AALL UTOS OWNED H AUTOSULED BODILY INJURY(Per accident) $ NON-OWNED eOPERTYl $AMAGE HIREDAUTOSAUTOS P $ B UMBRELLA LIAR / OCCUR CX00000522-01 9/28/2013 9/28/2014 EACH OCCURRENCE $ 1,000,000 ✓ EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ $ WORKERS COMPENSATION I WC STATU• O H- AND EMPLOYERS'LIABILITY Y I ry TORY LIMITS R ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Security Service Errors&Omissions PP00036987-01 9/28/2013 9/28/2014 1,000,000 each claim/2,000,000 aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. North Andover MA 01845 AUTHORIZED REPRESENTATIVE PORT Charles W.Flober ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD CENT NO.: 18016506 Stacy Gonyea 10/10/2013 4:24:06 Pri Page 1 of 1