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Home My WebLink AboutWiring Permit - Permits #13284 - 202 LACY STREET 5/6/2015 I ..... ... Date g OF r10RT�y,� TOWN OF NORTH ANDOVER * y� PERMIT F®R WIRING �gCHUS� This certifies has that :.....:...................................................,.................... permission to perform iK s 1 6 .. .... .....f Wiring m the buildin at =Y g'of ......................................................... . f ` North Andover,bass. f Fee ..... Lic. No ...... ... ........ I ,9 ti ELECTRICAL INSPECTOR ��` u ....... Check# � (,+� �/r ,r ) Official Use Only l�onnyto�tbd/ea&L o • Ma_dJacf _'e Permit No. / fA /.t t 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: April 27,2015 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) 202 Lacy St Owner or Tenant Robert Dickinson Telephone No. (978)973-4109 Owner's Address 202 Lacy St Is this permit in conjunction,with a building permit? Yes El No M (Check Appropriate Box) Purpose of Building 0 ; , A(", ',,\i'1( Utility Authorization No. Existing Service Amps / Volts Overhead El Undgrd E-1 _No.of Meters New Service Amps / Volts Overhead El Undgrd El 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 ollotiviia table may be waived by the Inspector of Wires. o.of Recessed Luminaires No.of Ceil.-Susp. (Paddle)Fans o.of Total Transformers KVA o.of Luminaire Outlets No.of Hot Tubs Generators KVA_ o.of Luminaires Swimming Pool Above In- o.of Emergency Lighting rnd. grnd. Battery Units o.of Receptacle Outlets No.of Oil Burners FIRE ALARMS o.of Zones o.of Switches o.of Gas Burners o.of Detection and Initiating Devices o.of Ranges No.of Air Cond. Total o.of Alerting Devices Tons g No.of Waste Disposers eat Pump Number ons KW No.of Self-Contained Totals: Detection/Alerting Devices o.of Dishwashers pace/Area Heating KW Local E-; Municipal Other Connection Security Systems:* o.of Dryers Heating Appliances KW - No.of Devices or E uivalent o.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent o.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 Wires. Estimated Value of Electrical Work: $850.00 (When required by municipal policy.) Work to Start: April 27,2015 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 C] BOND El OTHER 0 (Specify:) I certify, under the pains and penalties of perjury,that the information on this placation is tr and complete. FIRM NAME: DefUdej Security om LIC.NO.: C 1355 Licensee: ?' e- 1 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: Lie.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)El owner El owner's agent. Owner/Agent Telephone ERMIT FEE: $ Signature No. C , � A The Commonwealth of lAfassachtisetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, M4 02114-2017 rvlvw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu nib ers licant Information Please Print Legibly ie (Business/Organization/Individual): Defender Security Company.: Tess: 3750 Priority Way S Drive Sui,le 200 /Stoic/Zip:Indianapolis, IN 46240 Phone 9:800-68.9-9554 ou an employer? Check the appropriate box: Lcnon roject(required): I am a employer with 3 4. ❑ 1 am a general contractor and [ w construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. modelingI am a sole proprietor orpartner- These sub-contractors have .ship and have no employees molitionemployees and have workers' ildin additionworking for me in any capacity. gcomp. insurances[No workers' comp. insurance ectrical repairs or additionsrequird.J 5. ❑ We are a corporation and its1 qu a homeovmer doing all v;ork officer have exercised their umbing repairs or additionsmyself [No workers' comp. right of exemption per MGL of repairsinsurance required.]t c. 152, §1(4),and we have nother employees. [No workers' comp, insurance required.] )plicant that checks box I must also fill out the section below sliowing their workers'compensation policy information. owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;uors that check this box must attached an additional sheet showing the name of the sub•eonlractors and state whether or not those entities have ces. V the sub-contractors have employees,they must provide their workers'comp.policy number. yr employer tit at is providing workers'compensation insurance for my employees. Belowis the policy and job site nation. trice Company Name: MJ Insurance Inc TC2JuB1108L22613 Expiration Date: 10/712-8" 2 C0 / Nor Self-ins. Lic. r: — �1+`�' City/State/Zip: Cl tL � ice Address: W 1K1L :11 r1 copy of the workers' corn ensation policy declaration page(showing the policy number and expiration date). re to secure coverage as required under Section 25A of MGL c. 152 can lead.to the imposition of criminal penalties of a io to S 1,500.00 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 Officc of tigations of the DIA for insurance coverage verification. 'tereby certify tarder the pains at penalties of perjury that the information provided above is true and correct. A < Date: I �J Iturc: 8665023559 fcial use only. Do rat write in this area, to be Completed by city Or ton", ofJIcial, tv or Town: PermitfLicense suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other Phone 0: ontact Person: Commonwealth of Massachusetts I Department of Public Safety i seetwit}sNitt'111v 5-Licrme License: SSCO-001258t "t � ''+ lf t `-r2-• STEPHEN C EHRLICH , I 3750 PRIORITSX WY S DR 4206 INDIANAPOLIS IN 46240 r Iz Expiration: Commissioner 12/03/2016 .:: •,COMMONWEALTH.OF.MASSA&USETTS.: -- BOARQ�QF EL LYRICIANS ISSUES .THE FOLLOWING L't"CE'NSE A RMVSTEREa SYSTEM TECHNIC IA 4 STEP:REN C EHRL I`CH' s 369 CENTRAI_ `STREE'T +� UNIT-9 `FOXBOROUGH MA 02035 2637 45560 4A a of/31./,16 Please visit our aicb site at I)LLp://%•A.Aq.mass .gov/dpI/boards/EL DEFENDER SECURITY CO / PROTECT Y STEPIIEN C EHRL I CFI (FA) 3750 PRIORITY WAY SOUTH STE 200 INDIANAPOLIS IN 46240-3815 Fold,Then Ootanh Along All Perforations COMMONWEALTH OF MASS_ ACHUSETTS .. , !'�'•.!,_1.±'1t�!' I�..i'i.�!al ='a?L1C31�'r:.l=;.`.L�'��i��1:�11;1:___1 BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED SYSTEM CONTRACTOR a DEFENDER SECURITY CO / PROTECT Y N STEPHEN C EHRLICH w z 3750 PRIORITY WAY SOUTH W :J STE 200 INDIANAPOLIS IN 46240-3815 1355 C 07/31/16 38220