HomeMy WebLinkAboutWiring Permit - Permits #13087 - 129 CHRISTIAN WAY 1/28/2015 i
F rr
Date........ :........ ...........
...........
OF 40RTh 1
TOWN OF NORTH ANDOVER
o
PERMIT FOR WIRING
a �J ;sa
`4ACHU5rc
s
This certifies that
F f a has permission to perform .... ........ ........ ......... ........ .................................
j� wiring in the building of...................:` .=
............................................................................................
at .. .`: f.... North Andover,Mass.
:,... ...........Lic.No .:...:........ :.....Fee.....
......., `
ELECTRICAL INSPECTOR
Check#
% ,
L n1Y//O �""•a���� official Use obly
�y�ar�/ws at o`/.lnr„�►a ice permit No, A
BOARD OF FIRE PREVENTION REGULATIONS O '�C'and Fee Checked
ev. l/07) ve bleak
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code
(l1iEC),527 CMR 12.00
City or Town of. I ) O� Date: /
LE,4SEPMTININKORTYPE.4LL INFO I
By this application the undersi ed To the Inspector of Wires:
gn gives notice of his or her intenti to perform the electrical work described below. .
Location(Street&Number) G/ 3
tA- 0-cl
Owner or Tenant ,
Owner's Address _ �.�J.Q Telephone No.
7
la this permit in conjunction with a building permit? Yea El No
Purpose of Building (Check Appropriate Box)
Existing Service Am s Utility Authoriration No.
P / Volts Overhead❑ Undgrd❑ No.of Meters
HOL`&M-W n Amps / Volts Overhead❑ Und �
Number otFeeders and Ampacity ❑ Na.of
Location and Nature of Proposed Electrical Work:
t:.o lotion o the � "
No.of Recessed Luminaires allow table be waived the 1 ctor o wires
No.
.oof Cd l.-" sp.(Paddle)Fans 0.0 otba
No.of Luminaire Outlets Z'ransfonmers KVA
Of Not Tuba
No.ofLumiinsires ve
Swimming Pool o•a mergarcy
No.of Receptacle Outlets d ❑. a Generators KVA
d. Batxe Units
No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners 0.0 n an
No.of Ranges datialff Devices
No.of Air Cond. ° No.of Alerting Devices
Tons �No.of waste Disposers eat in um r one o.o
Tobls: lhwb on/Alertin Devices
No.of Dishwashers Space/Area Heating KW I,ocn10 an
No.of D Connection 0 offier
+a Heating Appilanm �
0.0 star KW o.o Na of s.
or nivalent
Heaters ' s 0.0
Ballasts Data Wiring `
No.Hydromassage Bathtubs Na at Devices or alert
No.olMotorx Total HP �
OTHER: Na atDevicp or ant
Estimated Value of Electrical Work: Attach additional detail#'dosing or as required by the In pector of wires.
Work to Start: ,- � (When required by municipal policy.)
—�� / �,/�, Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the the licensee provides proof of liability insurance inclu Performance of electrical wank may issue unless
ding"completed operation coverage or its substantial
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing offirLr��cat. ?!re
CHECK ONE: INSURANCE ❑x BOND ❑ 071M ❑ (specify:)
I cat*'ender the pains atdPenahler ofPu W rY,that the brform moon on this
FIRM NAME: NI htwatch Protection Inc. °PP on Is rate and eoxWete:
Licensee: PeUI Delslanor LIC.NO.: 7024C
Wly plicabk,enter exempt"in the license mmber line f LIC NO.:7024C'
Address: 22 Brietwood Drive, Westfarci Mq 01886 Bus.Tel.No.`8t38-72-9282
*Per M.G.L.c. 147,s.57-61,sec work Alt,Tel.No.:
afety
OWNER'S INSURANCE WAIVER: I am aware that theLicen Licensee no have the liability ran Na.
required by law. By my signature below,I hereby waive this requirement. 1 am the(check one ms°win CO K'ncto's BAY
Owner/Agent
Signature Telephone No. PERnfIT FEE.•S ! a
h
r i
The Commonwealth ofMassachusem
Department of Indus0WAccidents
Office oflnvesdgations
1 Congress Stree4 Suite 100
Boston,MA 02114 2017
wwwmassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): �q�t,'� ;�, Q
Address: SQ�V �� r
[1am
tate/Zi �a �(Y� (��`� Phone#:
an employer?Check the appropriate box:
a employer with__L�___ 4. ❑I am a general contractor and I Type of project(required):
loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
a sole proprietor or partner listed on the attached sheet. 7, ❑Remodeling
and have no employees These sub-contractors have
ing for me in any capacity. employees and have workers' 8' ❑pemolition
workers' comp.insurance comp.insurance.! 9. ❑Building addition
ired.] 5. ❑ We are a corporation and its 10.[)Electrical repairs or additions
a homeowner doing all work officers have exercised their 11. Plumb'
❑ mg repairs or additions
lf. [No workers'comp. right of exemption per MGL12. Roof repairs
nce required.]f c. 152,§1(4)i and we have no ❑
employees. [No workers' 13K Other
'Any applicant tha comp.insurance required.]
t checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 shed 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 providing workers'compensation insurance jor my em
information. ployees. Below is thepolky andjob site
Insurance Company Name:GUARD INSURANCE COMPANY
Policy#or Self-ins.Lic.#:NIWC531842 12/10/2015
Expiration Date:
Job Site Address: 2 YIS C�V ( City/State/Zip: /��Uk C(h�0,,�(,t, j�.t_�-� >
Attach a copy of the workers'compensation policy laration page(showing the policy number and-expiration date). l�3
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 ce under the pains and penalties o perjury that the information provided above is true and correct
Si tore: Date:
Phone
EEOther
only. Do not write in this area,to be completed by city or town qffleial.
n: Permit/License#
ority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on• Phone#:
®r A M izea Nightwatch
Protection, Inc.
50A NorUnyestem Dr.,Sufte 9
Sefem,NH 03079
Kevin Gilligan 15 H011Y St.,sutra 208
President ScOftrouph,ME 04074
tou free(M8)722-9282 x121
kg Bnlphtwatchprotectbn.com
www.nightmtchprotection.com
Commonwealth of Massachusetts
Department of public Safety
Security Svatema-S-Lfcenu ^— ---
License:SS401M "''
PAVL DEM ,
22 BRIARVVO�D
Westford MA
Commissioner Expiration:
Fold,Than tl UM AI&V AN Pwfoffloons
. flMIrf1QE6NNLTH,OF
f1 I A NS
.ISSUES THE. FOLLOWING L I C`fillSE AS
A MOIS71RED SYSTfm CONTRACTOR
NIGMATCH PROTECTIDN INC
PA11L J VELS I OM
22 BRIAFOMD DRIVE
WESTFBRD RA 01886-1165
7O24 C o7%31/16 50372 7Y