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210/095.A-0113-0000.0
N° 2253 Date............��.................
I AORT"
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SACMUSf
This certifies that ....... .1
hasp ermission to performE.....-: ..... ......., ................................
wiring in the building of
at. ::..:: t-...................... .North Andover,Mass.
Fde.�.....�....... Lic.No.......:�.. I..�,J�. �-�'� +�1:...........................
/�.. ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
Commonawaall of/7a.1aac1uulall.! Official Usc Only
Pcrmit No. r75�3
c �Ua'Parinurcl o�.}ira �arvicae
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS (Rev. 11i99J (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Mas nehusetts Electrical Code( ,IEC),527 F69NIft 12.00
(PLEASE PRINT IN INK OR TnY\PE;ILL INFOIX(TION) llatc: �. &3
City or Town uf: QO F `_1- i--(� 0a.0 0et2 To flee lnsInctor of J-Vires:
By this application the undersigned gives notice of his or her intego'n h to perform the electrical work described below.
Location (Street & Number) l 1'x'1
Owner or Tenant � 'a 0—1::�_I.e, Q P/Q, Telephone No.
Owner's Address
Is this permit iu conjunction'with a building permit? Yes ❑ No (Check Appropriate Box)
1'urliosc of Building Utility r uthurizntiou No.
Existing Service Amps / Volts Overhead ❑ Undani ❑ No.of Meters .
New Service Amps / Volts Overhead❑ -Undard ❑ No. ofil•leters:
Number of Feeders and Anhpacity
Location and Nature or Proposed Electrical Work: Ur. �Qr r m 2
• Cwu lesion of the I'olloui,rQ rcrble Wray be n•aired br the hes'senor or(t fres.
No.of Recessed Fixtures No.of Ccil;Susp.(Paddle)Fans No.of 'Total
Transformers KVA
No.of Lighting Outlets No.of I•lot Tubs Generators KVA
AboveIn- t o.o mergency tg hung
No.of Lighting Fixtures Swimming Pool gnhd. ❑ end. ❑ Batts Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARNIS No.of Zoiii:s.
No.of-Detection an
1 lo.of Switclhes No.of Gas Burners Initiating Devices s
No.of Ranges No.of Air Conal. Total ' No.of Alerting Devices
Tons o
No.of Waste Disposers fieatPunnp I i umber Tons h�Y h o.of Self-Contained
Tot21s-j Detection/Alerting Devices
No.of Dishwashers Space/Area Heating ICW Local IlYlunhcipal
onn -tion C] Othi r
No.of Dryers Heating Appliances KW '
.of Devices or Equivalent
No:of Water K1V No.of tVo.of Data iiriug:
Heaters Signs Ballasts No,of Devices or Equivalent
No.Hydromassage Bathtubs No.of iliolors Total HP . 'Telecommunications Wiring:
No.of Devices 0rEg uivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of;Vires.
R'
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
Elie licensee provides proof of liability insurance including"completed operation"covern__e 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 ❑ 0.1'I-IER ❑ (Specify:)
(Expiration Datc)
Estimated Value of Electri al Work (When required by municipal policy.)
Wort: to Start: / � Inspections to be requested in accordance with NMEC Rule 10,and upon completion.
I certify, undo r the paints and penalties of perjuq•,that the information an tlris application is trite and complete.P.s
FRUNI NANIE:. ADT SECURITY SERVICES, INC. LIC.NO.: C1533
Licensee: . � 1 /1 Signatur_011uS / LIC.NO.:C1533
(If applicable. enter"awitrpt"in the licence nunrberlitie•) Bus.Tel.N0.(7MT 78-1169
Address: 111 MORSE STREET,* NORWOOD, MA 0 16J Alt.Tel.No..81) 278-1131
OWNER'S INSURANCE WAIVER: I am a%,mrc that the Licensee dors not have the liability insurance coverage normally
required by lnw. By my signature below, 1 hereby waive this requirement. I am the(check onc) ❑ owner ❑ ow'ner's agent.
Owner/r\sent ��
Signature
TelcPhorie, u. F.AtILIT FEE: SST
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTINQ 1
(Print or Type)
NORTH ANDOVER , Mass. Date
a _ Ihuilding Location 3 ��jj�j Permit #
T Owners Name AA/"4 &'l
• - _ New Renovation Replacement Plans Submitted D
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BASEMENT
IST FLOOR
2N0 FLOOR
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3Rn FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
6TH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name Q�Corp.
Address1?1 Al
Partner.
46W_ �4 Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate the type of insurance cover ge by checking the
appropriate box:
Liability insurance policy Other type of indemnity Q Bond Ej
Insurance Waiver: I , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner L__.J Agent
1 hereby certify that all of the details and information 1 hare submitted (or entered)in above application ate true and accurate to the best of my
knowledge and that all plumbing work and installations performed under'Permit issued for this application will-be in compliance with ali pertinent
provisions of tho Massachusetts State Cas Code and Qupter 142 of the Genual laws.
By TYPE LICENSE:
Plumber
Titleasfitter' Signature f Licensed
City/Town: Master Plumber or Gasfitter
Journeyman aeW
APPROVED (OFFICE USE ONLY) Lice&nsA Number
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