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Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... . . ...................
................. r ...........................
has permission to perform . ........
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wiring in the building of �::� g -4 -ow`...
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at ::-r:./......-. .. 1 . ....
................................... . Northudover, Mass.
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Fee.... ........... Lic. No .............. ................1
EVC L JNSiE�
Check #
7852
11!
10
` •�........v.�woartn W massacnusetts Official Use Only
�y Department of Fire Services Pest No.
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked /Jo'_
[Rev. 1/07] (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 W INK OR TYPE ALL INFORMATION) Date: [ a — (0 �H-7
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned notice -of 's or her intention to erfo the ectrical work described belo
Location (Street & Number) ---� 0 . q® -C Sw�
Owner or Tenant
Telephone No.
Owner's Address7Jt7
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Is this permit in conjunction with a budding permit? Yes No
❑ (Check Appropriate Boz)
Purpose of Building Utility Authorization No.
Ensting Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
of Recessed Luminaires
No. of Luminaire Outlets
of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water KW
No. Hydromassage Bathtubs
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above ❑ la-
nd. d ❑
No. of OR Burners
No. of Gas Burners
No. of Air Cond. Iotal
Tons
Heat Pum umber Tons KW
Totals "......_"`.'. `.-.-
Space/Area Heating KW
Heating Appliances KW
No. of No. of
Sims Ballasts
of Motors Total HP
table may be waived by the tnenertnr tr w;.oma
o. of Total
Transformers KVA
Generators KVA
o, o mergency ig g
Battery Units
FIRE ALARMS
No. of Zones
No. of Detectio a and
Initiating -Devices
No. of Alerting Devices
o. of Se -Contained
Detection/Alerting Devices
Local [I Municipal
conn2s&& ❑ Other
Security Systems:*
tE uivalent
Data Wiring:
No. of Devices or Equivalent
Telecommunications Wiring:
No. of Devices or E uivalent
Attach additional detail if desired, or as required by t e nspector of Wires.
Estimated Value of Electrical Work: 1 0 (X (When required by municipal policy.)
Work to Start: 1 Z —0 •—(7Y 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 erage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCl BOND ❑ OTHER ❑ (Specify:)
I certify, under the ains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: i �•
' LIC. NO.:
Licensee: Signature LIC. NO.:
(Ifapplicable, enter," emp(" the li e number line. �-�
Address: 5 S I"l fV,ey ��� }� ows. Tel. No.: -� -,�30 �+
*Per M.G.L c. 147 s. 57 61 k � Alt Tel. No.:
> ty Dep Department o Public Safe "S" License: Lic. No.
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.
Owner/Agent
Signature Telephone No. PERMIT FEE: $�
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