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210/045.G-0025-0000.0
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HORTM
'f�"'°;•�"� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that .......... . J `r `�
has permission to perform G� � '�
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wiring in the building of.......... . .:.:............................................................
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Fee ?. '. .... Lic.No. %3 ...,,,,,,\!?^..`... !1... ....`.� `..
4 ELECTRICAL INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
Commonwealth of Massachusetts Official Use Only
,T Department of Fire Services Permit No. 5�l
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/991 lea,e blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code
M-CJ 527 CMR 12.00
11 Ido
(PINLEASE PRINT IN INK OR TYPE L OPOIMTION) Date:
City or Town of: To the Inspec or of fVires:
By this application the undersia gives no i e of his or her inten to perform the electrical work described below.
Location (Street& umber) 176 ffhit4in mc.
Owner or Tenant Telephone No.00,�
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 Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New� Sen•ice Amps / Volts Overhead❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of thefiolloivitig table may be waived by the Inspector o ;Vires.
No. of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No. of Total
Transformers KVA
No. of Lighting Outlets No.of Hot Tubs Generators KVA
Above In- o. o Emergency Lighting
No. of Lighting Fixtures Swimming Pool rnd. ❑ rnd. E] Battery Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones
No. of Switches No. of G—as Burners No. of Detection and
Initiating Devices
No. of Ranges No. of Air Cond. Total No. of Alerting Devices
Tons e
No. of Waste Disposers
Heat Pump Numt�cr Tons KW No. of Self-Contained
Totals: ....................... Detection/Alerting Devices
No. of Dishwashers Spacc/Area Heating KW Local ❑ Alunicipal El Other
e. Connection
Heating A Security ystems:
No. of Dners Appliances KW No. of Devices or E uivalent
No. of Water KW No. of No. of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, a•as required by the Inspector of;Vires.
INSURANCE COVERAGE: Unless waived by the owner,no permit for die performance of electrical work may issue unless
die 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 eviibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated.Value of Electrical Work: 'r (When required by municipal policy.) ~
Work to Sialt:: Inspections to be requested in accordance with MEC�Rule"10,.and upon completion:
I certify,under.the airs and penalties of perjury,that the information on this application is true and completes
FIRM NAME: ADT Security Services 111 Morse Street,No o , MA 062 LIC. NO.: 1533C
Licensee: John S.Bassett Signatu " IC.NO.: 1533C
(Ifapplicable, enter"exempt"in the license number line) Bus. Tel. No.: 781-278-1131
Address: Alt. Tel. No.: 781-278-1725
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have die 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/Agent40001
Signature Telephone No. PERMVIIT FEE: $ ,