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Home My WebLink AboutWiring Permit - Correspondence - 113 GREENE STREET 6/9/2014 Date .. � ��. o�NuaThq,�o TOl01lN OF NORTHANDOVER Sys, � •�� • CL i p PERMIT FOR WIRING CHUS�� e This certifies that has permission to perform �...�..,. ............................ wwmg in the building ...................................................... ,,North Andover,Mass at . o.Lic.N ......af .......... ELEEyawR ICsALI,N SPEC�TeO R � z,t F Check# Commonwealth of kamaclumetb Official Use Only Ac� ec// nn Permit No. rZ-��l part.d o/,.five Jervice� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 TY E ALL INFO TION) Date: U � ? I City or Town of: W C)V To the Inspector of Wires: _ By this application the undersigned gives notice'of hi s her intention perform the electrical work described below. to Location(Street&Number) I � SCeuu f • �.- Owner or Tenant OU Q Telephone No. �rjI `6 4 o 6 Owner's Address q 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 fiollowing table may be waived by the Inspector of Wires. 0 of No.of Recessed Luminaires No.of Ceil: p•(Paddle)Fans Sus PaddleTransTotal T Tsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA --- No,of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery 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 Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ munConnection ❑ Other No.of Dryers Heating Appliances KW Security Systems: 1 Y No.of Devices or Equivalent No.of Water Kam, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Vlectrical Work: L-(D (When required by municipal policy.) Work to Start: I t 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"comp!eted 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 (Ifapplicable, 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 a ent. Owner/Agent � 75� Signature Telephone No. PERMIT FEE: The Commonwealth of Massachusetts Department oflndustrialAccidents ti Office of Investigations d I Congress Street, Suite 100 o- Boston, MA 02114-2017 wwmmass.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 Dr. Suite 9 City/State/Zip: Salem, NH 03079 Phone #: 888-722-9282 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 13 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ 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 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 Sec.S st-Low Voltage employees. [No workers' 13.0 Other y 9 comp. insurance required.] *Any applicant that checks box#1 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 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Hartford Insurance Co. of the Midwest Policy#or Self-ins. Lie. #: 76 WEG EV7027 Expiration Date: 12/10/2014 Job Site Address: I I 'Ce City/State/Zip: MOK Attack a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).61 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjr ry that the information provided above its true and correct. Si ature: Date: 60 13/J Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: L ORIZED INightwatch ALER Protection, Inc. 50A Northwestern Dr.,Suite 9 Salem,NH 03079 Kevin (allll an 15 Holly St.,Suite 208 g Scarborough,ME 04074 President toll free(888)722-9282 x121 kg@nightwatchprotection.com www.nightwatchprotection.com t Commonwealth of Massachusetts Department of Public Safety Security Systems-S-License E License: SS-001696 t PAUL DELSIGPrO ' 22 BRIARWO()D Westford MA*18 � �0 Expiration: Commissioner 01/25/2016 Fold,'then Detach Along All Perforations 14f? FL.E>.CTR I C I AN$ ISSUES THE. FOLLOWING LI C'ENSE AS REGISTERED SYSTEMS CONTRACTOR NIG.HTWATCH PROTECTION INC PKUL J DE.LSIGRDR 22 D R I AT11400 D DRIVE W EST FORD 1AA OiI386mii65 7024 C 07/31/16 fPIP t'� K�N�y`r)