HomeMy WebLinkAboutHealth Permit # 7/2/2015 commonwealth of Massachusetts
- �° it Services
BOARD OF FIRE PREVENTION REGULATIONS
APPLICATION IT TO PERFORI
All work to be performed in accordance with the Massachusetts Electric
(PLEASE MWT ININIC OR TYPE ALL INTORMATION) D tc
City or Town of: NORTH ANDOVER To d
By this application the undersigned gives notice of his or her intention to perforir.
Location(Street&Number) s 3 tit l
OwnerorTenant ��
Owner's Address
Is this perinit in conjunction with aAuilding Permit? Yes ❑ No
Utility,A
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e.M verhead❑
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. KW
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0 °' Total IW.
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accordance wit
permit for the p
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undersigned certifies that such coverage is in force,and has exhibited proof of sG
CHECK ONE: INSURA=NCE"g BOND ❑ OTHER ❑ (Specify:)
Icertrfy, under the pins and penalties ofpeijuq,that the information on this
FIRM NAME: . 67
Licensee:J 4-AN U ,0 1,)kjr::.rA M Signature-'-, _
(If applicable,eat " xempt"in the ease n inber e.)
Address: _ �¢ � � -�a.)
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safet3
OWNER'S INSURANCE'WAIVER: I am aware that the Licensee sloes not h
required by law. By my signature below,I hereby waive this requirement. I am
Own er/Agent
Signature Telephone No.
commonwealth of Massachusetts Official Use Only
--_ Permit No.
Department it I
' Occupancy and Fee Checked
o BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank
APPLICATI.
I ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12 0
(PLEASE PRINT ININIC OR TYPE ALL.INFORMATION) Dates 'a.
City or Town of: 1>TC)RTH ANDOVER 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)_ 6 1, 4 J
Owner or Tenant c � Telephone No.
Owner's Address
Is this permit in conjunction with a uilding ermit? Yes ❑ No ❑ (Check AppropriateBor)
Purpose of wilding + - 4"�(_"� 6" Utility Authorization No.
- Existing Service Amps / 'Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity —
LoCation and Nature of Proposed Electrical Worlr �'y�r"° 'td
Completion of the fallowing table may be waived by the Inspector of Wires,
No.of Total
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA
KVA
No.of Luminaire Outlets No.of Hot Tubs
Above Generators o.o mergency ig ting
No.of Luminaires Swimming Pool rnd F1
In-rnd. ❑ Battery Units
No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No, of Zones
No.afDetection and
No.of Switches No.of Gas Burners Initiating Devices
Total No.of Alerting Devices
No.of Ranges No.of Air Cond. Tons g
Heat Pump N;umbei. Tons I£W,,,,,,,_, No.of Self-Contained
No.of Waste Disposers Totals: Detection/Alerting Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other
Heating Appliances KW Security Systems:*
No.of Dryers No.of Devices or Equivalent
No. of Water No.of Ballasts of Data Wiring: uivalent
Heaters I VV Signs Ballasts No.of Devices or E
Telecommunications Wiring:
No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent
OTHER.:
.flttach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with WC 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` - BOND ❑ OTHER ❑ (Specify:)
I certify, under ill and penalties of pejury�,that the inforriaatlar2 on dais r plicrttio�2 is true nnrl complete.
FIRM NAME: . A44cs 0 - �a� as J LIC.NO.:
Licensee: �, U .ttdp!'t" �?' � Signature � � °� LZC.NO
I:
(If applicable,ent ^ " xempt"in the ' erase n tuber e.) Bus.Tel.No.: ��
Address: e , .' F /0 , 0) Alt.Tel.No.:
'Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S'License. Lie.No.
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)❑owner ❑owner's agent.
Owner/Agent &Telephone No. MIT,�EE:
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