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Permit No.
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lug BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Ward
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORT(
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 1
(PLEASE PRINT IN INK O PE ALL 1 F MAT ON Date J10-46 Co
City or Town of � � ����� To the Inspector of Wires: m
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The undersigned applies for a permit to perform th electrical work described below. O
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Location (Street & Number) l�f l� l�Ii ' -v
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Owner or Tenant "1 1.12`cA� L
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Owner's Address _ z
Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) I
Purpose of Building Utility Authorization No.
Existing Service Amps_J Volts Overhead ❑ Undgrnd ❑ No. of Meters
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New Service Amps_l Volts Overhead ❑ Undgrnd ❑ No.of Meters �D
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Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Installation O f alarm yet e m
No. of Lighting Outlets No.of Hot Tubs No.of Transformers Total =
KVA
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No.of Lighting Fixtures Swimming Pool Above
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gmd_ ❑ grnd. ❑ Generators KVA v
No.of Emergency Lighting O
// No.of Receptacle Outlets No.of Oil Burners Battery Units z
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No.of Switch Outlets No.of Gas Burners -0FIRE ALARMS No.of Zones
No. of Ranges No of Air Cond. Total No.of Detection and
tons Initiating Devices G7
Heat Total Total O
No. of Disposals No.of r-
Pumps Tons KW No.of Sounding Devices
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No.of Self Contained Z
No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices C/Do
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No.of Dryers Heating Devices KW kLo:w
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Connection ❑Other O
No.of No.of Voltage
No.of Water Heaters KW Signs Ballasts Wiring O
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No. Hydro Massage Tubs No_of Motors Total HP
OTHER_ �..e-�R 2 _ 1 M
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INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts General laws 1 have a current Liability Insurance Policy indud- r-
ing Completed Operations Coverage or its substantial equivalent.YES O NO D 1 have submitted valid proof of same to the Office. m
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YES O NO O If you have checked YES,please indicate the type of coverage by checking the appropriate box.
INSURANCE X% BOND O OTHER O (Please Specify)
n (Expiration Date) a
Estimated Value of Electrical 'o $ v r �{ A
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Work to Start Inspection Date Requested: Rough Final ^��� / O
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Signed under the Penalties of Perjury: -<
FIRM NAME
LIC. NO. T 2 31 C
Licensee Signature
LIC_NO.
Bus.Tet.No 617-431-5800
Address 60 William St /Wellesle�r, MA O 1R1 AILTeLNo'61T 4'3T R'i7
OWNER'S INSURANCE WAIVEf t am aware that the Uoerrsee does riot have the insurance coverage or its substantial equivalent as re-
squiredb7/;Matis`General Laws.and that my signature on this pertnd apPrtcation waives this requirement..Owrter AgeM
(Please
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No:;�=PERMIT FEES < '`1�
Date. 4 ..CT. .2946
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i. ° t„`°,• "° TOWN OF NORTH ANDOVER ffl
swim, PERMIT FOR WIRING
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r This certifies that ...A..Q J.......5. 4......5.... �:k.....5..... ...............
yhas permission to perform .......... // �'j SyYS ��
wiring in the building of..........�`..d �' r U
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at........f ....fh9.!.1.. r:.............................. .North Andover,Mass.
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Fee...�A..:......... Lic.No. ... .......1.4...........................................................
ELECTRICAL INSPECTOR
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t WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File
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