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Home My WebLink AboutInsurance Letter - Permits #12469-1 - 58 COMPASS POINT ROAD 7/8/2015 7 Date..... ... .. .� ............... p10RTl� ?°;�� TOWN OF NORTH ANDOVER ° s PERMIT FOR WIRING n "• ip ` (� �983^CHUg�� rThis certifies that .....................: ..."..:................. . ...!........ ,..................................................... has permission to perform .::: d.. ... .................................. wiring in the building of,.. �` ......................................... 9 � � ,North Andover,Mass. at ., � .......... ., Fee„ Lic.No. � d�� ... d..��':` .. ..de?.r'' .P.:.r...l!.... Q. ............. ...... ELECTRICALINSPECTOR Check# I Oinnionwacxhlt o f cajdac6a.aJettJ Official UseOnly Offtct Permit No. _,/_)eP ar rru n1 0/31're Servica:� Occupancy and Fee Checked , BOARD OF FIRE PREVENTION REGULATION [Rev. 1/07] (,euveb,ank) 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: June 26,2015 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) 58 Compass Pt Owner or Tenant Alexandra Warren Telephone No. (781) 244-9901 Owner's Address 58 Compass Pt Is this permit in tt conjun� on wi a bu th ilding permit? . ......_Yes L..�_..__-_,_No I I __(Check Appropriate Box) Purpose of Building i 1 e� � `v� _ t "��% A� Utility Authorization No. Existing Service Amps / Volts Overhead 0 ..� Undgrd � No.of Meters New Service _._._ Amps / Volts.._ Overhead L. _Undgrd I 'I ..._.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 ollowin table naay be waived by,the Inspector of Wires. No,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- No.of Emergency Lighting rnd. grrid. I Battery Units o.of Receptacle Outlets No.of Oil Burners FIRE ALARMS o.of Zones o.of Switches No.of Gas Burners o.of Detection and Initiating Devices o.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g O.of Waste Disposers eat Pump Number oils KW No.of Self-Contained Totals: I IT I Detection/AlertingDevices o.of Dishwashers S ace/Area Heating KW Local Municipal Other p g I. Connection L-� o.of Dryers Heating Appliances______---------KW Security Systems:* .............. No.of Devices or Ec uivalent No.of Water KW No.of No,of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs lNo.of Motors_- Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail rf desired, or as required by the Inspector of Wirer. Estimated Value of Electrical Work: $850.00 (When required by municipal policy.) Work to Start: June 26,2015 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 P] BOND[.] OTHER (Specify:) I certify, under the pains and penalties of perjury, that the information on s a at* ' ue and complete. de•FIRM NAME: Defen Securit Co a LIC.NO.: C 1355 Licensee: ! t' ,- —Signature LIC.NO.: D 434 (If applicable, eater"exempt"in the licenseBus.Tel.cense number line.) _ _._. _. 1 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) ...I owner C..')owner's agent. Owner/Agent Telephone ERMIT FEE: $ Signature No. The Commonwealth of Massachusetts Department of InditstrialAccidents Office of A vestigations 1 Congress Street, Sidle 100 Boston, AM 02114-2017 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ilicant Information Please Print Legibtv ie (Business/Organization/individual); Defender Security Company_ ress: 3750 Priority Way S Drive Suile 200 ,/State/Zip: Indianapolis, IN 46240 Phone 9;800-68,9-9554 'ou an employer? Check the appropriate box: Type of project(required): I ?rn a employer with 3 4. 0 1 am a general contractor and I cons -ac ors 6. Ej New construction have hired the sub-contractors employees (full and/or part-time).* Remodeling I am a sole proprietor or partner- listed on the attached ed sheet E] Remodeling 8. E] Demolition ship arid have no employees These sub-contractors have working g for me in any capacity. employees and have workers' 9. E] Building addition nsurancff.1 (No workers' comp. insurance 5. E] We are a corporation and its 10.0 Electrical repairs or additions required.] 0 work officers have exercised their 11.0 Plumbing repairs or additions I am a homeowner doing all v, right of exemption per MGL 12,E] Roof repairs myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.]t employees. [No workers' 13.El Other camp. insurance required.] ._ I 'S UOX MUSt also compensation policy information. pplicant 013t ChL:Ck riii out the section below showing their workers' owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affindavit indicating such. !ctors that check this bo-<must attached an additional sheet showing the name of the sub-contractors and state whether or not illosc entities havc If the sub-contractors have crT1P10Yccs,they must provide their workers'comp.policy number. 7 it employer that is providing workers'compensation insurance jar my employees. B etc iv is cite policy acid job site nation. trice Company Name: MJ Insurance Inc Pr or Self-ins, Lic. P':TC2JuB1 1081-22613 -E'4catiori Date: 1 0/7/24� 20 ice Address: city/state/zip: j :It ,, copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ,c to secure coverage as required under Section 25A of MGL c. 152 can le.a.d.,zo the imposition of criminal penalties of a :p to S 1,500.00 and/or one-year impris 6nment, 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 ci-a(ioris of the DIA for insurance coverage verification, tereby certify totdc,r the pains and penalties of perjury that the information provided above is true and correct. r " ate ,A) Q � 8665023559 Ticial use only. Do not write in this area, to be completed by city a,-town, ofjiciat II tv or Town: PermitfUcense 4 s uing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other on tact Person: Phone Commonwealth of Massachusetts I Department of Public Safety S"[Int)S\itC i), S- 1.1utn't i License: SSCO-001258 STEPHEN C EHRLICH 3750 PRIORTTY WY S DR#206 INDIANAPOLIS IN 46240 f Expiration Commissioner 12/03I2016 COMMONWEALTH.OF-MASSACHUSETTS. : :' o ep, lijill . e e •- :,-,BQARQ�OF E.LE.CTR I C I ANS; :`ISSUES THE FOLLOWING LtCE'NSE A"°REGISTERED SYSTEM TECHN I C I A S , . STERREN C EHRL I CH 1 , 5369 CENTRAL�STREET UNJT.9 `FOXBOROU.G,H.: AA 02035-zL45560 434.o:;: o7/31./a nrrr3c "aiff ,,. a. .e1 0 PIcase visit our web site at liLLp://�•n,nr.niass .gov/dpl/boards/EL DEFENDER SECURITY CO / PROTECT Y STEPHEN C EHRLICH (FA) 3750 PRIORITY WAY SOUTH STE 200 1NOIANAPOLIS IN 462110-3815 Fold,Then Dolach Along All Perforalion s COMMONWEALTH OF MASSACHUSETTS -BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED SYSTEM CONTRACTOR a DEFENDER SECURITY CO / PROTECT Y 0 STEPHEN C EHRLICH w 3750 PRIORITY WAY SOUTH W STE 200 INDIANAPOLIS IN 46240-3815 1355 C 07/31/16 38220 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.