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-ID
Date.... /.Z.....— ..................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. 4;..: ...... 67-t4]z .. L, .. .......
has permission to perform ........
wiring in the building of ....... ......
..............................................
at ............LI ! 7 ...... ..... . North Andover, Mass.
4,4 ........ f�--� ............ -.Fee—S Lic. No. 1�41Y ...... .
Check # ELECMICAL INS"XI*qR
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 9 Use,3
Occupancy and Fee Checked
[Rev. 11/99] 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 ORT PE ALL FORMATION) Date: Id, — / c—/ 0 OWE' 1 e
City or Town of: �f-4 h j,- Lv t To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perf or—m- the electrical work described below.
Location (Street & Number) *0 -TI- `" o 1 J-TPAWAj
Owner or Tenant % jr ,, s ,4- C-0 f --
Owner's Address ,'. 1/72v ter'. -'f T.,, 0P(' 1rf' �e ci (C.s
Telephone No. �R$ j��Q 1 322
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorizaz
No.
Existing Service Amps / Volts Overhead ❑ Undgrd o. of Meters
New Service ts� Amps i2o / zy o Volts Overhead L� Undgrdo. of M�seters
P:umber ofFeecle. and A:npacity 4'z- �/ Z y 3 7
Location and Nature of Proposed Electrical Work: 7-71 - V , 'Ce
Completion of the.following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In- Elo.
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. o Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
I Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. of Water KW,
Heaters
o. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
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 2 B ND ❑ OTHER ❑ (Specify:) 0,1+
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: f 2 — / d Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the painsnd penalties of perjury, that the information on this application is true and complete
FIRM NAME: Cd/..��.r C�vr c L�� LIC. NO.:����
Licensee: /rn, C -44e- ( �.� ti ✓ Signature '
(If applicable, enter "exempt" in the lliice}ye numbee dine.) U /
Address: �f�%/ �/,�f'r /' tV d C7�`E 5 ✓�
OWNER'S INSURANCE WAIVER: I am aware that the Li see does
required by law. By my signature below, I hereby waive this requirement.
Owner/Agent
Signature Telephone No.
`-- ,C. NO.:
Bus. Tel. No.; 3 j
Alt. Tel. No.:
not have the liability insurance coverage normally
I am the (check one) ❑ owner ❑ owner's agent.
PERMIT FEE. $ 5r-
f / 3 P/117
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