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Home My WebLink AboutWiring Permit - Permits #13196 - 548 FOREST STREET 4/1/2015 S Date. '...... �................... w ? .'• °o` TOWN OF NORTH ANDOVER * : PERMIT FOR WIRING BgCHUS� � � A �. This certifies that ...."' . - ... _ ... d ... has permission to perform . i wiring in e building of Y" v ....... A� E k at ....:.. r z E... _ ...... North Andover,Mass. ... ......a € Fee..... .. ............Lic.No � k................ .......... ELYcTRICAL rNSPECTOR Check#_ k � � x Official Use Only o aat.�onwoa�ll'liz of `�a�.9datJalaat�, Permit No.x Occupancy and Fee Checked � + BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank).... ...---'----____. 'r 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: March 19,2015 City or Town of: North Andover,MA_ To the hmpector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 548 Forest St Owner or Tenant Keith Chaney Telephone No. (617)448-2774 Owner's Address 548 Forest St Is this permit in conjunction with a bull, ing permit? Yes❑ No W (Check Appropriate Box) Purpose of Building_S l [,_ull j`-"j(Aj 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 may be waived by the Inspector of 1Vires. No.of Recessed Luminaires No.of Ceil.-Susp. (Paddle)Fans o.of Total Transformers KVA No. of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n In- No.of Emergency Lighting rnd. grnd. atter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS o.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total o.of Alerting Devices Tons No,of Waste Disposers Heat Pump umber oils I{W No.of Self-Contained Tir IN IT I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:*No.of Devices or E nivalent 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 elecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of GVires. Estimated Value of Electrical Work: $850.00 (When required by municipal policy.) Work to Start: March 19,2015 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. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE W BOND G OTHER❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on dais cation is true and complete. FIRM NAME: Defender Securi ComQanX LIC.NO.: C 1355 Licensee: '" a' Signatur ,LIC.NO.: D 434 (If applicable,enter"exempt"in the license number line.) _ Bus.Tel.No.: 800-689-9554 Address: 3750 Priority 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)0 owner ❑owner's agent. Owner/Agent Telephone ER T FEE: $ -x;.w- Signature No. 4� V2_k"', cl�l The Commonwealth of Massachitsetts — Departtttent of InditstrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, AM 02114-2017 iviviv.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Con'tractors/Electricians/Plu nib ers licant Information Please Print Legibly l✓ (Business/Organization/individual); * Defender Security Company.: ress: 3750 Priority Way S Drive Sui,le 200 /State/Zip: Indianapolis, IN 46240 Phone#;800-68.9-9554 ou an employer? Check the appropriate box: r. N project(required): I am a employer with 3 4. ❑ 1 am a general contractor and I ert construction employees (full and/or part-time)." have hired the sub contractorsI am a sole proprietor or partner- listed on the attached sheet. emodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers.'comp. ❑ Building addition [No workers' comp. insurance comp. a corpora required.] ' S. ❑ We are a corporation and its : 10.* Electrical repairs or additions I am a homeovmer doing all work officers have exercised their 1 IQPlumbing 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 employees. [No workers' 13•❑ Other comp. insurance required.] ipiicant that checks box�"I must also GII out the section below showing their workers'compensation policy information. owners who submit this affidavit indicating they are doing nit work and then hire outside contractors must submit a new affidavit indicating such. ciors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have ees. If the subcontractors have employees,they must provide their workers'comp.policy number. rrr employer drat is providing workers'compensation irrsarance for my employees. Below is the policy and job site riation. trice Company Name: MJ Insurance Inc — TC2JuB1108L22613 'Expiration Date: 10/7/ 20 Gj �r or Self-ins. Lic. r: (1 — ite Address: 'T to w �J City/State/Zip:, Yo i J QL�T t A,4 1 � It a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). •e to secure coverage as required under Section 25A of MGL c, 152 can lead.to the imposition of criminal penalties of a o to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tigations of the DIA for insurance coverage verification. rereby certify under fire pains andTalties of perjury that the information provided above,is true and correct. lure: 1 1 tg CI�Vt /�' Date. 1=� 8665023559 ff Ticral use only. Do nat write it, thLs area, to be Mlipleted by city or town ofJlclal. II ty or Town: PermitfL,icense r# >uing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other ontact Person: Phone R: �! Commonwealth of Massachusetts ! Department of Public Safety S-111-hN Sstona S-Licenev License: SSCO-001258 ter. STEPHEN C EHRLICH ;, < 3750 PRIORTtY WY S`DR"�#20k, INDIANAPOUS IN;46246 A' ' Expiration: Commissioner 12/03/2016 ;::Y,-,COMMONWEALTH.OF.MASSACHUSETTS.: =: `. o e o • e e ARP.-'OF ELE.eTRICIANS ISSUES,. T,IJE FOLLOWING .LI"C'ENSE A REG'I'STERED SYSTEM TECHN I C I A STEE:H E N C EHRLLCH iW 369 CENTRAL' STRE.ET:' '�'!t.' i� UN;IT 9 r fOXBOROUGH MA 02035 263* 434 of/3 ./,16 45560 PIcase visit our vicb site at help://%•n.n.i.nlass .gov/dpl/boards/EL DEFENDER SECURITY CO / PROTECT Y STEPHEN C EHRLICFI (FA) 3750 PRIORITY WAY SOUTH STE 200 INDIANAPOLIS IN 462110-3815 Fold,Than Oelm:h Along All Perforations COMMONWEALTH OF MA_SSACHUSETTS �BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED SYSTEM CONTRACTOR Q M a DEFENDER SECURITY CO / PROTECT Y z N STEPHEN C EHP,LI CFI w 3750 PRIORITY WAY SOUTH W J STE 200 INDIANAPOLIS IN 46240-3815 1355 C 07/31/16 38220