HomeMy WebLinkAboutMiscellaneous - 22 Forest Street (2)`)
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... .................................................
......................................
has permission to perform ......................................................
wiring in the building of ....... ....................................................
P 1`101111 A'1.111
........ ... I . ... ... North Andover, Mass.
Fee6�� .............. Lic. No. ....... .
R
ELECTRICAL INSPE
Check # 5�5
A 9 1 A
-,
S-\_ Commonwealth of Massachusetts Official Use y /
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ( ), 52 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 524
City or Town of NORTH ANDOVER To the Inspec or o Wi es:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant P Gti
Owner's Address Cl 1,
AJ,
Telephone No.
Is this permit in conjunction ithn a building permit? Yes ❑ No Zr (Check Appropriate Box)
Purpose of Building � Utility Authorization No.TIP
Existing Service /0 a Amps Volts Overhead Q Undgrd ❑ No. of Meters i
New Service P 00 Amps / Volts Overhead ET Undgrd ❑ No. of Meters
Number of Feeders and Ampacity / oto
Location and Nature of Proposed Electrical Work:
of., Kd-
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires C)
No. of Ceil: Susp. (Paddle) Fans �.�
o ot
Trr al ansformers KVA
No. of Luminaire Outlets
No. of Hot Tubs 0
Generators ( KVA
No. of Luminaires
Sip In- ❑
nd. rnd.
o. o mergency ig gg
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of SwitchesNo.
11�Initiating
of Gas Burners
o. oDetection an
Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
Pu
Totals:
. um , er
ons
o. o e - ontam
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW ,�
cipal
Local ❑ Connection ❑ Other
No. of Dryersr
Heating Appliances KW
Security Systems:*
I
No. of Devices or Equivalent
No. of Water KW
o. o ___ � No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motot�fiotal HP
r trial:
Telecommunications, NDevices
No. of Devices or Equivalent
OTHER:
/?
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of 1 'cal Work: qV (When required by municipal policy.)
Work to Start:} 25 o Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO RAGE: 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete:
FIRM NAME:)Cly tW C tJ LIC. NO.: IS
Licensee: YI i 'v e/4T,Signature LIC. NO.:
(If applicable, enter, `exe t" in the cense numm6er line.) Bus. Tel. No.-`� 9 �o
Address: % d lye f✓ iur
EA.Alt. Tel. No.•
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safet"S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ins ce coverage normally
required by law. By.iny si a below I hereby waive this requirement. I am the (check one) owner ❑ owner's agent.
Signaturegent _ Telephone No. 7 7S '0 1 3 PERMIT FEE: $