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Home My WebLink AboutWiring Permit - Permits #13265-1 - 19 FOXWOOD DRIVE 4/13/2016 Date �NORT{i TOWN OF NbRTH ANDOVER ti� m * := * PERMIT FOR WIRING CHUgE I This certifies that c� has permission to perform e �- ........ .....7.. wiring in the building of `•. LO .................... ....... at ......... ....... . j ? I • .............................,North Andover, Mass. Fee:...... ........Lie. No. .... ............................. ................................................. ELECTRIC...... ALINSPECTOR Check# •� �. ��99// �rriclal use only ot;Prrnonwaa&L o f Vca-idaac� 4vff.4 tT Permit No. (1 apartnwn.,( of ira Sortdcaj Occupancy and Fee Checked 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: March 30, 2016 City or Town of: North Andover, MA To the Inspector of Wires: 3y this application the undersigned gives notice of his or her intention to perform the electrical work described below. ; ocation(Street&Number) 19 Foxwood Dr 3wner or Tenant John Pickett Telephone No. (617)775-4884 owner's Address 19 Foxwood Dr (s this permit in conjuncts ith a building permit? Yes No _(Check Appropriate Box) ?urpose of Building Utility Authorization No. E3:isting Service Amps / Volts Overhead ,Undgrd _ _ _„_No.of Meters yew Service Amps / Volts Overhead _ Undgrd ------No.of Meters .......... vltmber of Feeders and Ampacity : ocation 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 Wire to.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total I)ransformers KVA Ito.of Luminaire Outlets No.of Hot Tubs Generators KVA 10.of Luminaires Swimming Pool Above In- o.of Emergency LightingH nd. grnd. Battery Units 1o.of Receptacle Outlets No.of Oil Burners FIRE ALARMS o.of Zones 1o.of Switches No.of Gas Burners o.of Detection and Initiating Devices 1o.of Ranges o.of Air Cond. Total o.of Alerting Devices g Tons 1o.of Waste Disposers eat Pump umber ons o.of Self-Contained Totals: Detection/Alerting Devices 1o.of Dishwashers Space/Area Heating KW Local Municipal Other Connection 1o.of Dryers Heating Appliances KW Security systems:* y g Pp _................. No.of Devices or Equivalent lo.of Water KW o.of No.of Data Wiring: Heaters I Signs Ballasts No.of Devices or Equivalent Ito.Hydromassage Bathtubs o.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent )THER: Attach additional detail if desired, or as required by the Inspector of Wire ;stimated Value of Electrical Work: $850.00 (When required by municipal policy.) Vork to Start: March 30,2016 Inspections to be requested in accordance with MEC Rule 10,and upon completion. NS'URANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless se licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The ndersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. ;HECK ONE: INSURANCE IV BOND OTHER (Specify:) certify,under the pains and penalties ofperjury,that the information on t pplication is true and complete. IRM NAME:Defender Security Com an . LIC.NO.:C 1355 n � ,icensee: — a!°� 1=j` ( -I- C Si - �' gnature �..�.--�i LIC.NO.:D 434 f applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 800-689-9554 Lddress: 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 )WNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally -quired by law. By my signature below,I hereby waive this requirement. I am the(check one) owner owner's agent. )wner/Agent Telephone ,ignature No. [PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia _J Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeObly Name(Business/organization/Individual): Defenders Inc. dba Protect Your Home Address: 3750 Priority Way S Drive Suite 200 city/state/zip: Indianapolis, IN 46240 Phone#: 317-810-4720 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition w employees and have workers' orking for me in any capacity. 9. ❑Building addition [No workers'comp.insurance comp. insurance.1 required.] 5. [] We are a corporation and its 10,W Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L[]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 13 ❑Other employees.[No workers' comp.insurance required.] *Any applicant that checks box#1 must also till 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 tl:e policy and job site information. Insurance Company Name: M J Insurance Policy#or Self-ins.Lie.#: TCJ U B 1116 LO3015 Expiration Date: 07/01/2016 Job Site Address: 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 certify under the pains and,penalties of perjury that the information provided above is true and correct. Sip�ature 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#: COVIMO WEALt H OF 11lMASSAC�WSET T S CONTROL # - s6ARD OF IMPORTANT :ELECTRICIANS ISSUES THE FOLLOWING LICENSE A If your license is lost,damaged or destroyed;is inaccurate;or A:REG f ST€RED SYSTEI.1 CONTRACTOR "\h needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. DEFENDER SECURITY CO / PROTECT Y � N �w This license is subject to Massachusetts General Laws and S T EPHEN G EHRL,L CH — z regulations.Your license is a privilege,and cannot be lent or 3750 PRIORITY WAY SOUTH w assigned to any person or entity under penalty of law.Keep this rt�o license on'your person or posted as required by law and/or STE 200 � regulations. {NOIANAPOLIS IN 46240-3515 1355 C 07/31/16 38220 COMMONWEALTH OP MASSAC€ USETTS CONTROL# ri U s �: i w� too I N _ ..._, BOARD OF IMPORTANT ELECTRICIANS ISSUES THE F 0 L LOW I N G L`I C E N S E � If your license is lost,damaged or destroyed;is inaccurate;or A �. needs to be corrected,visit our web site at mass.gov/dpl for A REGISTERED SYSTEM T E C H N I C I A': a= instructions to ensure the proper mailing of your Renewal �. 1 14 Application and any other correspondence. STEPWEN C EHRL I CH lla This license is subject to Massachusetts General Laws and 1 regulations.Your license is a privilege,and cannot be lent or 369 CENTRAL STREET t `W assigned to any person or entity under penalty of law.Keep this } \,U license on your person or posted as required by law and/or UNIT S regulations. F OXBOROUGH 1,IA 02035-2637 434 D 07/31116 45560 -T i> - Employer: DEFENDER SECURITY COMPANY � r f SSCO-001258 STEPHEN C EHRLICH ' 3750 PRIORITY N Y S DR 9200 INDIANAPOLIS IN 46240 For DPS licensing information visit: www.Mass_Gov/DPS 12/03/2016 NOTICE OF COMPLETION OF ELECTRICAL WORK Pursuant to M.G.L. c. 143, § 3L, Stephen Ehrlich hereby provides written notice to the inspector of wires that the electrical work outlined in the preceding permit application has been completed.