HomeMy WebLinkAboutHealth Permit # 11/20/2006 Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. L/,
I Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blanl<)
APPLICATION I
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORA,1ATION) Date:\\- 0 ® tom (,0
City or Town of: NORTH 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) � °®" �`(°O+r°ry ,D�
Owner or Tenant =� \ se—S Telephone No.
Owner's Address �
Is this permit in conjunction with a building permit? Yes—S No ❑ (Check Appropriate Box)
Purpose of Building �r��,���®, Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
RECEIVED'
NOV 0 2006 Date.. . " s 1 ..,,. ....
wing table may be waived by the Inspector-of Wires.
ANDOVER No.of ota
T Transformers KVA
,r rl w I TOWN OF NORTH ,ANDOVER
�� ... K
o Generators VA
PERMIT FOR WIRING IT6—.76TT,mergency Eigliffing
❑ Battery Units
*�•'`4+.r,o "ay* F[RE ALARMS ENo. f Zo nes
�ss�cwus� l? .M f° o.o Detection an
f , F Initiatin Devices
This certifies that ........... � t ..... .......................... No. of Alerting Devices
p t.,.
y : "'.m::.......................... o. o �Sel - ontame
has permission to perform ......... �":
`�'�'�"�'�i""' "' � Detection/Alert'n Devices
..........
wiring in the building of :; :. ... °... ................. ❑ Mollie necti l ❑
.........•••••••••••••••••• Local Connection Other
i.��
North Andover,Mass.
Security Systems:*
at.. ; .,� ^� r(«••�-•�.I 1�"�•� ��'...••.•••.•• � No.of Devices or E uivalent
j
LiC��OA` .2 ° P .1 �a , f 1P r Data Wlrin
r
a
Fee,°.:..w ..:...:..,. a. . ................ �.�. r�s a - ..,� No.of Devices or Equivalent
ELECTRICAL INSPECTOR'
elecammunrcahons rang:
Check N — �`� ""— - No.of Devices or E uivalent
r 0 O - if desired, ot•as required by the Inspector of Wires.
Kc4uucu uy ii, mcipal policy.)
Work to Start: N OlA 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 ❑ BOND ❑ OTHER ❑ (Specify:)
certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: 0\
_ e6 '(„ LIC. NO.:
Licensee: '�. `�°�, ��„��C,�,�� Signatur e LIC. NO.:! �,J
(11'applicable, enter "exempt"in the license number line.) Bus. Tel. No..,(WAW 16kk g
Address: K` x *° Alt. Tel. No.:
*Security System Contractor icense required for this work; if applicable, enter the license number here:
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.
Own nt FERNfIT FEE: $
Signature tore Telephone No.