The URL can be used to link to this page

Home My WebLink AboutWire Permit - Permits #13161 - 4 EVERGREEN DRIVE 3/7/2016 WR S\ m O 11 Le ` NNER \\ o \\ 111 RTH 4 IONIC! ,,j� 0 N OF NO TOW mom IRI O pI, . 111 IN MEMO: \ S that ... , ,.. 1. Th isIS \ certzf e has ge salons pero ... ...,,.. .. 'c ow �\ rm In the building of....... �Ku... �,.. y A �,.. Wiring E \O \ ' North Andover, Klass. a....... . ..,... , . ..... ...... . .. .... O , ... \\ at W c .......... \\\ e y NE \ No .. .... .I c. ELECTRICALSPETORFEe..... .... ..... \` IS BEER 10 ff \ME Check 4112 \` NMI, 'q, 172 "_ rclal use t�nry o d a PerrnitNo. 1 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: February 19, 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. vocation(Street&Number) 4 Evergreen Dr owner or Tenant Sanjiv Shrivastava Telephone No. (732)343-5498 owner's Address 4 Evergreen Dr Is this permit in conjunction with a build in permit? Yes No (Check Appropriate Box) ?urpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Undgrd Na.of Meters new Service Amps / Volts Overhead Undgrd No.of Meters number of Feeders and Ampacity :ocation and Nature of Proposed Electrical Work: Installation of a low-voltage,wireless burglar alarmsystem. Completion of the following table may be waived by the Inspector of Wire 1o,of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Total Transformers KVA 1o.of Luminaire Outlets No.of Hot Tubs Generators KVA 1o.of Luminaires Swimming Pool Above In- No.of Emergency Lighting nd. grnd. Battery Units 1o.of Receptacle Outlets No.of Oil Burners FIRE ALARMS o.of Zones Flo.of Switches No.of Gas Burners o.of Detection and Initiating Devices 4o.of Ranges No.of Air Cond. Total o.of Alerting Devices Tons do.of Waste Disposers eat pump umber ons o.of Self-Contained Totals: Detection/Alerting Devices 1o.of Dishwashers pace/Area Heating KW Local Municipal Other Connection Jo.of Dryers Heating Appliances m_ m KW ecurtof D vices or Equivalent fo.of Water KW o.of No.of Data Wiring: Heaters Sians Ballasts No.of Devices or Equivalent io.Hydromassage Bathtubs No.of Motors Total HP elecommunications 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: February 19,2016 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 (Specify:) certify,under the pains and penalties ofperjury,that the information on is pR tion is true and complete. 'IRM NAME:Defender Security Company LIC.NO.:C 1355 ,icensee: � Signature LIC.NO.:D 434 If applicable, enter "exempt"in the license number line.) V 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 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. )caner/Agent Telephone ignature No. E 7 FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I � 600 Washington street r` Boston,MA 02111 -�° www.mass gov/dia Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant.Information Please Print Lathy Dame(Business/Organizationllndividual): 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): L N 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 $. ❑Demolition working for me in any capacity. employees and have workers' insurance.I 9• ❑building addition [No workers'camp.insurance comp• 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 I LE]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 fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 job site information. Insurance company Name:_ M J Insurance Polity#or Self ins.Lie.#: TCJ U B 1116 L03015 Expiration Date: 07/01/2016 Job Site Address: City/State/Zip: _ -Ai cw� - Attach a copy of the workers'compensate 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 penalties of p that th n munion provided above is true and correct. Si tune: /" Date: Phone#: 75 - C�2- 55�j 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#: COMMONWEALTH OF MASSACHUSETTS CONTROL# BOARD OF IMPORTANT 'ELECTRICIANS ISSUES THE. FOLLOWING L I CENSE A�, if your license is lost,damaged or destroyed;is inaccurate;or A P E G I STE R E D SYSTEM CONTRACTOR ry, � needs to be corrected,visit our web site at mass.govldpi for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. DEFENDER SECURITY CO 0 PROTECT Y # This license is subject to Massachusetts Genera!Laws and 5 T EPIIEN C EHFtL i Ci! ;' regulations.Your license is a privilege,and cannot be lent or 3750 PRIORITY WAY SOUTH assigned to any person or entity under penalty of taw.Keep this STE OO ..v license on'your person or posted as required by law andior regulations. NDIANAPOLIS IN 46240-3815 1355 C 07/31/16 38220 R ".ROMMONWEALTH,OF MASSACHUSETTSCONTROL# LJ p z rtI e si"t' t- , jmi 12, zwis BOAR t t F IMPORTANT ELECTRICIANS ISSUES THE FOLLOWING LICENSE ," if your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.govldpi for A REGISTERED SYSTEM TEChN I C I A � }� instructions to ensure the proper mailing of your Renewal Application and any other correspondence. STEP HEN C EHRL!CH This license is subject to Massachusetts General Laws and i regulations.Your license is a privilege,and cannot be tent or 369 CENTRAL STREET assigned to any person or entity under penalty of law.Keep this UPI I T license on your person or posted as required by fativ andior regulations. 434 D 7 t3XBOR0I.IGH MA 02035-263 �7r�1i16 45.56u � a Employer: DEFENDER SECURITY COMPANY 10-11 SSCC3-04'I 2�8 STEP HEN C EFIRLICH 3750 PRIORITY NW S DR 9200 INDIAitiAPOIJS Iiti 46240 For DPS Licensing information visit: www-h4ass.Gov/DPS tzra3nals 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.