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The Commonwealth of Massachusetts t,K Onh
T
-� Permit No.
Occupancy & Pee Checked _
Department of Public Safety 3/90 (ka%v blank)
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE`, ALL INFORHATION) Date&' /y a
City or Town of flit/%%/Jf/lr To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
N-ner or Tenant
Owner's Address 9.,) 6',11 .v v s
Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building6jcyeil JUO® Utility Authorization NO.
Existing Service Amps 1-20 / ?yo Volts Overhead ❑ Undgrd ❑No. of Meters
�erheadNew Service Amps / VoltsUndgrd ❑ No. of Meters
Number of Feeders and Ampaci
Location and Nature of Proposed Electrical Work /'ewer/
No.
of Lighting Outlets
No. of Hot Tubs=
No. of Transformers Total
KVA
No.
of Lighting Fixtures
g g
Above
Swimming Pool grnd.
❑ In- ❑
grnd.
Generators KVA
No.
of Receptacle Outlets
No. of Oil Burners
No. of
fEmergency Lighting
BatteryNo.
of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
No. of RangesNo.
of Air Cond, Total
tons
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local ❑ Municipal ❑Other
No. of Disposals
p
No. of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
Connection
No.
of Water Heaters KW
No, of No. of
si7,ns Ballasts
Low Voltage
lWiring
No.
Hydro Massage Tubs
No. of Motors Total HP
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 C3 NO ❑ I have submitted valid proof of same to this office. YES ❑ NO
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) /'Lfjiy 1etp /_ / 6 �"
Estimated Value of Elecrrical Work S (Expiration Date
Work to Start e l4�1_ Inspection Date Requested: Rough Final
Signed under thepenaltiesof perjury:
/,1/22c
FIRM NAME Le6l f J';j{ le I/ l� y%l/t,/6 LIC. NA.
Licensee � ,�LyL ,� �'�we1zw Signature LIC. NO. /i/ 9/97
Address 40 %" Ol Bus. Tel. No. S6d- ���- s'��
Alt. Tel. No. ifs- f -0 0/C9
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 pe
� V
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S J
Signature of Owner or Agent
7 -2
H36
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AcmUS
Date ......
TOWN OF NORTH ANDOVER
R
PERMIT FOR WIRING
This certifies that ....... f�-O.S��R ..... SAU.k ........ ....................
has permission to perform ...... .......... 0 .......................
wiring in the building of ...... M..T'.A�A ...... Q..ev.p
;f .............................. I ......
CU
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... 0.�. 4 <>
..r ... A 00
at .1_76 ........ ...... I ........ . North Andover, Mass.
Fee930.......... Lic. NoA/V ..............................................................
ELECTRICAL INSPECTOR
Ck (+(637
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer