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Date .... (z.. . eq . 0� .....
........... .... ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ ...... ..............................
has permission to perform ............ ......... .......................
.......... ... ..... .. ........ ...
wiring in the building of ........ 'Y.. 4 " =... ...0 .......................
at ......... / .... F ..../ ... Y.W.—V )C-4 P ..... PR ............ . North Andover, Mass.
Fee ..5--.S.— Lic. No. ..............
.......................
Check # MpEcrow-*-
LECTRICAL
7087
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 70 F;7
Occupancy and Fee Checked
[Rev. 9/05] (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: % Z — S ,l
City or Town of: ,� ,, To the Inspector of [Vires:
By this application the undersigned gives notice of his or her`intention to perform the electrical work described below.
Location (Street &
Owner or Tenant
Owner's Address
Is this permit in conjunction with a buildinepermit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building c �., t Utility Authorization No. ,�� /`"`-
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service I py Amps Volts Overhead ❑ Undgrd ®--- No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion td the followln tbl b ' d
a e
.ynacn aaanronat detail �fdesired, or as required by the Inspector of 1 res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: jz _ f—_G/ 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 cover a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: IC. NO.: X33
Licensee Signature - LIC. NO.:
(If appGcahle, en r "exempt" in tlT�license number line.) Bu"1'el. IVo.• l�7— Z/oy
Address: — S;`— It. Tel. No.:
*Security System Contractor License required for this work;Vipplicable, enter the icense 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'agent.
Owner/Agent s t
Signature Telephone No. PERMIT FEE.
may a waive !LL the lns ector o Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of otal
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool ove ❑ n- ❑
o. of Lmergency Lighting
rnd. grnd.
Batter
y Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. o etection an
Initiating Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
He ump
umber
onsKW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Kunicipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
ecurity ystems:
No.
No. o ater
of Devices or Equivalent
Heaters KW
o. o o. o
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
TelecommunicationsWiring:
No. of Devices or Equivalent
OTHER:
.ynacn aaanronat detail �fdesired, or as required by the Inspector of 1 res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: jz _ f—_G/ 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 cover a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: IC. NO.: X33
Licensee Signature - LIC. NO.:
(If appGcahle, en r "exempt" in tlT�license number line.) Bu"1'el. IVo.• l�7— Z/oy
Address: — S;`— It. Tel. No.:
*Security System Contractor License required for this work;Vipplicable, enter the icense 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'agent.
Owner/Agent s t
Signature Telephone No. PERMIT FEE.
5-6411 - a/c / ?- - 7 - PX -y
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