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Home My WebLink AboutWire Permit - Permits #12983-1 - 81 CANDLESTICK ROAD 12/23/2015\ \ 01 \ \ \\\ � Date .. .. ........� ... .. ......... �on RrORK <$ T ` 0 �. ,- •. \ - ANDOVER I gm d91L I M Al :.HU ¢T This certifies that ... . .... . . .has permission to perform ........ 800 wiringin the building of . .. .. ..... ............. ................................................................... �\ IR at .. ............ . ...... ............................a IRS North Andover, MassNO WIN ONE s - FeLic. Igo. ...,.. �....... .................... ........... e....... ...:................. 1 ELECTRIca� INSPECTORgzo �_ Cheek A �� uniciai use uray PermitNo. 1,21111 —I Occupancy and Fee Checked BOARD OF FIFE PREVENTION 1TIO REGULATIONS [Rev. 1/071 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: December 11, 2015 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. vocation(Street&Number) 81 Candlestick Rd awner or Tenant Jaime Gennetti Telephone No. (978)683-6833 owner's Address 81 Candlestick Rd [S this permit in conjunction with a building permit?n .1. Yes , - No 1�, (Check Appropriate Box) ?urpose of Building : : Utility Authorization No. existing Service Amps / Volts Overhead`.. Undgrd . . No.of Meters Vew Service Amps / Volts Overhead LJ Undgrd w.i _No.of Meters number of Feeders and Ampacity vocation 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 of 1o.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.Trans Total sformers I{VA do.of Luminaire Outlets No.of Hot Tubs Generators KVA JO.of Luminaires Swimming Pool Above In- o.of Emergency Lighting nd. il,,J grnd. atter Units io.of Receptacle Outlets No.ofOil Burners FIRE ALARMS o.of Zones 1o.of Switches o.of Gas Burners o. Detection and Initiatin Devices 1o.of Ran es o.of Air Cond. Total o.of Alerting Devices g Tons io.of Waste Disposers eat Pump umber ons o.of Self-Contained p Totals: Detection/Alerting Devices 10.ofDishwashers ace/Area Heatin KW ocal Municipal x Other P g Connection 1o.of Dr ers Heating Appliances_ KW Security systems:* Y g PP No.of Devices or Equivalent lo.of Water Kw o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent 1o. a H dromassa Bathtubs o.of Motors Total HP elecommunications Wiring: Y g No.of Devices or Equivalent )THER: „ Attach additional detail if desired, or as required by the Inspector of Wir` stimated Value of Electrical Work: $850.00 (When required by municipal policy.) Vork to Start: December 11 2015 Inspections to be requested in accordance with MEC Rule 10,and upon completion. NSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless .ie 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°+ BOND ,. OTHER L.1 (Specify:) certify,under the pains and penalties ofperjury,that the information on this application is true and complete. ° IRM NAME:Defender Security Company LIC:NO.:C 1355 acensee: eAZ�WkP ,i-e Signature -�° ° �wi:1C.NO.:D 434 f applicable, enter "exempt"in the license number line.) Bus.Tel.No.:800-689-9554 ° .ddress: 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 ofPublie 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) .,.1 owner t owner's agent. )wner/Agent Telephone ignature No. ERMIT FEE: $ 1. 11 ,-fD1 l ; r - A,I The Commonwealth of Massachusetts --ta-� --: , Department of Industrial Accidents F- - — =y Office of Investigations r w 600 Washington Street r . ,' y 1" Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le `b Name(Business/Organizataon/Individual): Defenders Inc, dba Protect Your Home Address: 3750 Priority Way S Drive Suite_200 city/state/zip: Indianapolis, IN 46240 _. Phone 4:. 317-810-4720 Are you an employer?Check the appropriate box: Type of project(required): 1.[Z I am a employer with? 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. []Demolition employees and have workers' _ wrtrkint for me its any cal?ac�ty. . 1 P.,.. a � _.._ i`. �.. Y:,1YA'Lt CAkg..L11.fi:ilCiYXRk [No workers'camp.insurance comp, insurance.; 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 11.❑ 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 employees. [No workers' 13.[1 Other comp. insurance required.] 'Any applicant that chocks 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. tContraetors 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 the policy and,lob site information. Insurance Company Name: M J Insurance Policy#or Self-ins.Lic.#: TCJ U B 1116 LO3015 Expiration Date: 07/01/2016 Job Site Address: CLI Ike4ltt I\ City/State/lip: 1 .H r 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 ofa 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 penury that the information provided above is true and correct Si mature: � Date: Phone# ( £i -" 5 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 Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: w 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.