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9656
Date......... . .... ... . :f .. ...
..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...................... 14 o —j
..................................... . ..............................
has permission to perform .......... ................
wiring in the building of ........... ...........................................
at �.,O.
� . ........................ . Orth Andover, Mass.
Fee9.� .... . ...... Lic. No. ........
L
Check # 32- 9 2-8 9r ECTRICAL INSPECTOR
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C'ommonweaR of Ma63a7clwaffi
_ 1JaParfman� o��ira Jarvicas
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. � 3 0
Occupancy and Fee Checked _
(Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date,' 9-1-/
City or Town of: kApi- N A,u(I n9l To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) a / G e Q, A -d ICS /
Telephone No. 78�� s �7/�v
Owner*or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service rkmpS - ! Volts
New Service .Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters R
No. of Meters
Completion o the following table may be waived b the Inspector of Wires.
No. of Recessed Luminaires
No. of CeU. Sus . addle Fans
P (Paddle)
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In -o.
Swimming Pool rnd. nd.
o mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners _:
FIRE ALARMS
No. of Zones
o. and
No. of Switches
No. of Gas Burners
atingon
Initiatin Devices
No. of Ranges
No. of Air Cond. Tonsl
No. of Alerting Devices
Heat Pump
umber
Tons KW
o. ofSelf-Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal _Capnectton'�
No. of Dryers
Heating Appliances KW
Se u ty S ste
or Equivalent
No. of WaterKms,
o. of o. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
elecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total Hr
No. of Devices or Eq uivalent
OTHER: /,77-Z 3
QQ Attach additional aerait rf aesirea, or as requireu uy inc iiuy6C -j,, .• w•
Estimated Value of Electrical Work: �7- (When required by municipal policy.)
Work to Start: .roe_ Inspections to be requested in accordance with NEC Rule 10, and upon completion.
INSURANCECO�E: 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 W BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that the information. on this application is true and complete.
FIRIM NAME: U ('ltA- 4 Ser V i Gam' LIC. NO.:
Licensee: c 1,` Signature LIC. NO.: /cc" - 0
(If applicable, enter "exempt" in the license number lin ' / Bus. Tel. No.: (03,5 G
Address: % (�. L/�7 Cfi') c I) %� /k��/`S %* �QVg Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "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 PERMIT FEE: $05
Signature - Telephone No.
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