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Home My WebLink AboutWiring Permit - Permits #11758 - 209 JOHNSON STREET 8/1/2013 Date......... "..... - ...:..................... °p N0pTH�~ TOWN OF NORTH ANDOVER 9 ° n PERMIT FOR WIRING t �BACHUg� This certifies that ......... .... ...... :.. b 'A' has to perfo . .. .... ....................................wiring in the building of......,, , `.. b I at ` ........ ... ,North Andover,Mass. f ...,... .. �f s Fee Lic.No. E s� �I LECTRICALINSPFZMR.' 6 Check# �� N, lfommonweahk o f Haddad efd Official Use Only i tf y c� �7 low 2epadment o/J`ire Serviced Permit No. 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),T 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE AL INFO ION) Date: / u City or Town of: To the Inspector of Wires: By this application the undersigne gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ao C� �0 hrn o ST Owner or Tenant 0'C C`f Telephone Noq Owner's Address �( ?� 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: t-AO A i gf1 1C )2CuYi �I 51,3yet`n Completion of the fiolloudng table may be waived by the Inspector of N'ires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No,of Luminaire Outlets No.of Hot Tubs Generators KVA �� No.of Luminaires Swimming Pool Above Ei In- El .oEmergency Lighting rnd. rnd. BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No. I Detection and nitiatin Devices (� 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 t� ....................... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kam, Securi No.of De isteces or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW 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 ff"ires. Estimated Value of Electrical Work: L{ U (% (When required by municipal policy.) Work to Start: iu)I l 13 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 (Ifapplicable, enter "exempt"in the license nwnber 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ` ,�Q The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 % , 71, Boston, MA 02114-2017 . 5 www.mass.gov/dia Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers AIn) icant 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.Z 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' [No workers' comp. insurance comp. insurance. $ 9. ® Building addition required.] 5. ® We are a corporation and its 10.E] Electrical repairs or additions 3.EJ I am a homeowner doing all work officers have exercised their I L n 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 Volta employees. [No workers' 13.R1 Other Y 9e 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 is providing 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:12/10/2013 Job Site Address: �a C1 )O\,)n3on City/State/Zip: 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 cer•ti under the pains and penalties qfperjuLy that the in ornration provided above is true and correct. Signature E Date: J U 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#: - Please visit our web site at http://www.masy.gov/dp|/boardo/EL , ' N|GHTV4TCH PROTECTION INC PAUL J D[L5 |CNDR (FA) 22 BR/AHWU0D DRIVE Nightwatch DEALER Protection, Inc. 1-0 N[\TFORD MA.Ul886-ll65 sn*Northwestern o,.Suite u Salem,w*nouro .Gilligan1onv|�ex nuneoox Kevin Gilligan so",uomuD' .Mso4n7x President xxik^o(888)722*28ex1e1 kg@niomwmtchpmte000n.00m www,mghxvauhpm|ncounxom cnnmonwrvN, ofgnsschvsexs Dcpnxmcn\ u/ Public Safety 1,.*onacSS-001688 PAQLD8LSIGNOR 22 BRJ&RWOODDR Westford RA01VV6 -- ------ 92~` Expiration commusmoe, 01/2512014 , Fold,Then Detach Along All Perforations 9OARD OF ISSUES THE FOLLOWING LICENSE AS & REGISTERED SYSTEM CONTRACTOR N>QHTWATCH PROTECTION INC p8DL J Q[LD|@WOR 22 BR|0RWO0D DRIVE � 1,1E8TFOKD NA O)886-| 165 . 7024 C 07/31/16 50372 ,��`~��"°�°=�^="��m'*w�q�*