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Home My WebLink AboutWiring Permit - Permits #13098 - 458 FOSTER STREET 2/5/2015 Date . . . TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU This certifies that ,; ; E , z has permission to perform ... . i wiring in the building of .,.... ,..... ....................... `.. " North Andover,Mass. at ...... .. s. Fee...... .......Lic.No. ..` ......... ......±. i ......... ..... �. ... : r.. .'i....... ELEC CAL INSPECTOR j Check# Letter View Page 1 of 2 pp /�j��! // Official Use Only (fomrAonwa alik o f YVa-dj ac►2ra3ef6 Jer it No. 2.part..1 o13#ira arvic�� Occupancy and Fee Checke . ' 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 TYPE ALL INFORMATION) Date: January 23, 2015 City or Town of: North Andover,MA To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) 458 Foster St Owner or Tenant John Rogus Telephone No._ (978)685-8188 Owner's Address 458 Foster St Is this permit in conjunction with a building permit? Yes ❑ No Fs/] (Check Appropriate Box) Purpose of Building R )G l-�rio.�t 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: Installation of a low-voltage,wireless burglar alarm system. Completion of the following table inay be lvaived by the Inspector of 6fires. 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- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS o. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices o.of Ranges No.of Air Cond. Total No. of Alerting Devices Tons g NO.of Waste Disposers Heat Pump umber ons V No.of Self-Contained Tials: rDetection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection Security Systems:* No.of Dryers Heating Appliances KW _No.of Devices or Equivalent No.of Water KW 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 ff"ires, Estimated Value of Electrical Work: $850.00 (When required by municipal policy.) Work to Start: January 23,2015 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. d, C. , Vi k https://www.citizenserve.com/Admin/PermitController?Action=CheckPrintingConditions... 1/23/2015 Letter View Page 2 of 2 The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 9 BOND❑ OTHER❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is trite and complete. FIRM NAME: Defender Security Company LIC.NO.: C 1355 AI V — Licensee: Signature LIC.NO.: D 434 (If applicable, enter"exempt"in the license number line.) Bus.Tel.No.: 800-689- 9554 Address: 3750 Priority Way S Drive,Suite 200, Indianapolis,IN 46240 Alt. Tel.No.: 866- 502-3559 *Per M.G.L. c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. SSCO- 001258 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 Telephone ERMIT FEE. Signature No. https://www.citizenserve.com/Admin/PermitController?Action=CheckPrintingConditions... 1/23/2015 The Commonwealth oflllassachusetis Department of lit dustrialAccidettts Office of Investigations 1 Congress Street, Suite 100 Boston, AM 02114-2017 i vw m mass.go vId is 'Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers icant Information Please Print Legibly e (Business/Organization/Individual); Defender Security Company_ -ess:3750 Priority Way S Drive Suite 200 State/Zip: Indianapolis, IN 46240 Phone #:800-689-9554 )u an employer? Check the appropriate box: Type of project (required): am a employer with 3 4. ❑ 1 am a general contractor and I 6. ❑New construction mployees (full and/or part-time). have hired the sub-contractors am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling hip and have no employees These sub-contractors have g, ❑ Demolition vorking for me in any capacity. employees and have workers.' 9 ❑ Building addition No workers' comp. insurance comp. insurance,t 5. ❑ We are a corporation and its 10.* Electrical repairs or additions equired.J am a homeowner doing all v:ork � officers have exercised their 11.❑Plumbing repairs or additions nyself. [No workers' comp. right of exemption per MGL 12•❑ Roof repairs nsurance required.]t c. 152, §I(4),and we have no employees. [No workers' 13.0 Other comp, insurance required.] )licant 013E checks box k I must also fill out the section below showing their workers'compensation policy information. wners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new aEfidavit indicating such. tors that check this box must attached an additional sheet showing the name of the sub-eonvactors and state whether or not those entities have :s, if the sub-contractors have employees,they must provide their workers'comp.policy number. r employer that is providing workers'compensation insurance for rrty errtployees. Below is(lie policy and job site ation. Ice Company Name: MJ Insurance Inc — N or Self-iris. Lie. ', :TC2JuB1108L22613 _-EXpiration Date: 10/7/2@'" e Address: �F �—��'`=�1 City/State/Zip: � lam. I � ' a copy of the workers' compensation policy declaration page(showing the policy number and piration datea to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine o S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of gations of the DIA for insurance coverage verification. treby certify under the pain.�snd penalties of perjury that the information provided above is trite and correct. ire. Y l Date:V 8665023559 cial use only. Do not write in this area,to be completed by city or town official. (I or Town: PermitfLicense 4 Ilse Commonwealth of Massachusetts f �J Department of Public Safety License: SSCO-001258 f STEPHEN C EHRLICH 3750 PRIORTI:Y WY S DR 4206� INDIANAPOLIIS IN 46240 ` Expiration Commissioner : 12/03/2016 COMMONWEALTH-OF MASSACHUSETTS.: .". TO • •::BQARQOF ,ELE.CTRICIANS;=:: ISSUES ,THE FOLLOW LNG L ME`NSE G I'STEREG SYSTEM TECHNIC I Acc STERAEN C EHRLI,CH 369 CENTRAL STREET .0 UN:IT_9 FOX BOROUGH AA 02035 2637 434. o. 0' 31./;:16: 45560 PIcase visit our web site at !1LLp://1-AdW.niass .gOv/dpi/boards/EL DEFENDER SECURITY CO / PROTECT Y STEPHEN C EHRLICH (FA) 3750 PRIORITY WAY SOUTH STE 200 INDIANAPOLIS IN 462110-3815 Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS . �``..',��!?I..'".h:•I-�jial 1=��iC3��`/,�1�}�("i��t} iJl !:,._=c� -DOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED SYSTEM CONTRACTOR Q a DEFENDER SECURITY CO / PROTECT Y N STEPHEN C EHRLICH W 3750 PRIORITY WAY SOUTH W S I t 200 INDIANAPOLIS IN 46240-3815 1355 C 07/31/16 38220