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The Commonwealth of Massachusetts P.—il No.
Occupancy & Fee Checked
Department of Public Safety 3/90 (leave blank)
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BOARD OF RRE PREVENTION REGuunoNs 527 CMR IZW
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance writh the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
"I To the Inspector of Wires:
TOWN OF TWW—GRI�B N,
The undersigned applies for a permit to perform the electrical work desc�rib-d-below.
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Location (Street & Number)
-0mrr-or Tenant
Owner's Address / / 'n 1� P 4- V / e- (�v
Is this permit in conjunction with a building permit: Yes El No ZI (Check Appropriate Box)
Purpose of Building &7-p G.0��a;n, Utility Authorization NO.
Existing Service Amps Volts Overhead El Undgrd 11 No. of Meters_
New Serv-ice Amps Volts OverheadEl UndgrdEJ No. of Meters
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work
No.
of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
No.
of Lighting Fixtures
Above
Swimming Pool grnd.
E] In-
grnd.
—KVA
Generators KVA
No.
of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No.
of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local Cl Municipal
Connection1:10ther
No. of Ranges
Total
No. of Air Cond. tonq
No. of Disposals
Heat Total Total
No. of Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No.
of Water Heaters KW
No, of No. of
Signs Ballasts
Low Voltage
Wiring
No.
Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES E] NO F] I have submitted valid proof of same to this office. YESE] NO []
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE 58'BOND [] OTHER [] (Please Specify)
Estimated Value of Electrical Work S (Expiration Da . teT
Work to Start — Inspection Date Requested: Rough Final
Signed under the penalties ofperjury:
FIRM NAME
Licensee
.LIC. H11.
Address Bus. Tel. No. - 6XL0 / E.:E
—Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one) &
I Telephone No.— PERMIT FEES C)
(Signature of Owner or Agent) 4
N2 Date../
r .............
VkORT)i
04
TOWN OF NORTH ANDOVER
.0 PERMIT FOR WIRING
This certifies that ........ . ........... ................. ...........................
has permission to perform .........................
wiring in the building of ......... ............... :'t ...... ....................
at,:.. .... ............ 7� ................. ........... rth Andover, Mass.
.....................
FeePe/o.l)!.��.. Lic. No ..... ///,)
.. ...... ...............................................................
ELECTRICAL INSPECTOR
C V kt '3 3 12/15/97 04:24 100. 00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Location
No. Date v
TOWN OF NORTH ANDOVER
Check #
'i 7582
Building Inseror
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
A*
Other Permit F!��
$
TOTAL
$
Check #
'i 7582
Building Inseror
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