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Home My WebLink AboutWiring Permit - Permits #11964 - 1015 FOREST STREET 10/28/2013 Date f. ......... �6 µORTM .t.• .; .'• °°� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,88ACHUg� y This certifies that i'...C;..........................................`� . l ;.................. ............ has permission to perform ............. ..... : .. ......... k........ ........: wiring in the building of.... ..... .♦..r ° .....,North Andover,Mass. at .... .�� ...... ........ .... �... ...... In Fee. a .........Lic.No.t t n ......... ...... . ..... } ........... ...... .,....;.. ELECTRICAL INSPECTOR ES'fi�s Check# { F f (fommonwea&o f Mamackmef I Official spl Only o/.t c/ire Serviced Permit No. (/t�'�`L+, �LJePar!?ment Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION l work to be peFOR rmed 1PERMIT TOdance with the aS PERsachusetts FORM lectrical�ELECTRICAL oWORK (PLEASE PRINT IN INK OR TYPE ALL INFORMA IO Date: bN �J City or Town of: NO( /� �( To the Inspector of Wires: By this application the undersigned Ives notice of his or her inte tion to perform the electrical work described below. c Location(Street&Number) d` s rf-s-t Sir Owner or Tenant No o a Telephone No. Owner's Address j(`(�� 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 �t1 Number of Feeders and Ampacity -- Location and Nature of Proposed Electrical Work: Completion of the followingtable 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 c�1 No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Units Emergency 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. I Detection and Initiatin Devices r_r No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis posers Heat Pump ""Number Tons I.KWI No.of Self-Contained p Totals: ' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mun'c Connect ❑ Other No.of Dryers Heating Appliances Kam, Security f be iSvsteces or Equivalent No.of Water No,of No.of Data Wiring: Heaters KW Si Ens Data No.of Devices or Equivalent ications No.Hydromassage Bathtubs No.of Motors Total HP Tel No.of Devices or Equivalent OTHER: /`,l Attach additional detail if desired,or as required by the Inspector of Wires. "® Estimated Value of lectri al Work: $ 4 V V (When required by municipal policy.) Work to Start: 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. PERMIT FEE: $ ( ' The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 u Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I,e�ibly Hanle (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): 1.21 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 $, ® Demolition working for me in any capacity. employees and have workers' 9. ® Building addition [No workers' comp. insurance comp.insurance. required.] 5. 0 We are a corporation and its 10.® Electrical repairs or additions 3.[:J I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself, o workers' comp. right of exemption per MGL y � t p c. 152 1(4),and we have no 12.E] Roof repairs insurance required.] ' § 13.R 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, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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. Lic. #: 76 WEG EV7027 Expiration Date:12/10/2013 Job Site Address: '��5 Vb(e S: - S-� City/State/Zip:� 0A Wwjl G l g 4 5 Attach a co f h workers' py o the� o ers 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 certify under the pains and enalties ofperiug that the information provided above is true and correct Sig Lriature: Date: 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,mass.gov/dpl/boards/EL NIGHTWATCH PROTECTION INC PAUL J DELSIGNOR (FA) 22 BRIARWOOD DRIVE Nightwatch WESTFORD MA.w886-ii65 Protection, Inc. 50A Northwestern Dr.,Suite 9 Salem,NH 03079 15 Holly St,,Suite 208 Kevin Gilligan Scarborough,ME 04074 President toll free(888)722-9282 x 121 kg @ nightwatchprotection.com mvw.nightwatchprotection.com Commonwealth of N1assachusetis Department of Public Safety License: SS-001696 PAU1,DELSIGNOR 22 BRIARWOOD DR Westford MA 01886 91-4— Expiration Commissioner 01/25/2014 Fold,Then Detach Along All Perforations -e—lRiONWEALTH OF M- ASSACHUSEI fa. 0 J b a-Aft 00 ✓ rLt:EfAICIANS ISSUES THE FOLLOWING LICENSE AS Uj A REGISTERED SYSTEM CONTRACTOR NIGHTWATCH PROTECTION INC PAUL J DELSIGN-011 22 BRIARWOOD DRIVE WLSTrORD MA 01886-1i65 7024 C 07/31/lI6 50372 X