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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ..........................,7� We- �- ...............
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has permission to perform........
Nviring in the building of ...........................
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Fee ..7.? .. . ......... Lic. No::��. .... ............
CMR
Check #
5103
Official /Use On[
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Permit No. (� ^!J �
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BOARD OF FIRE PREVENTION REGULAIONS 527 CMR 12:00
APPLICATION FOR PERMI To : ERFORM ELECTRICAL WORK
All work to be performed in accordance h the assachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date Id)-Vc,
To the Inspector of Wares:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number /7 J'7- 7 3 /ul G f��✓1
Owner or Tenant G
Owner's Address
Is this permit in conjunction with a building permit Yes 0 No X (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service l no Amps a -i V Vofts Overhead 0 Undgmd 9-/ No. of Meters
New Service Amps Voits Overhead a Undgmd 0 No. of Meters
Number of Feeders and Ampacity.
Lotition and Nature of Proposed Electrical Work J /Se�wu.2. r
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Poficy including Completed Operations Coverage or its substantial equivalent YES` / NO -
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indi�to the type of coverage by checking the appropriate box.
INSURANCE V BOND a OTHER - (Please Specify) �}/d Z /) C -
(Expiration Date)
Estimated Value of. El rica Work$
Work to Start c� (�� Inspection Date Resquested Rough Final
Signed under the Pe alties of perjury:
FIRM NAME LIC. NO.
Licensee u1n, ?tl 1(m, nature LIC. NO. 3S66 K /Z
Address o1h,
rj7JL�ZY[�'rl=ice
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
`-
Telephone No. PERMIT FEE $ v
(Signature of Owner or Agent)
Total
No. of Lighting Outlets _
No. of Hot fuse
No. of Transformers KVA
Above 0
In 0
No. of Lighting Flxtures
Swimminq Pool gind 0
gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Batlery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. Ekiposal
No. Pumps
Tons
KW
No. of Sounding Devices
NoJ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
0 Other
No. of dryers
Heating Devices
KW
Local Connection
on
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wirin
No. Hydro Nbssage Tuds I
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Poficy including Completed Operations Coverage or its substantial equivalent YES` / NO -
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indi�to the type of coverage by checking the appropriate box.
INSURANCE V BOND a OTHER - (Please Specify) �}/d Z /) C -
(Expiration Date)
Estimated Value of. El rica Work$
Work to Start c� (�� Inspection Date Resquested Rough Final
Signed under the Pe alties of perjury:
FIRM NAME LIC. NO.
Licensee u1n, ?tl 1(m, nature LIC. NO. 3S66 K /Z
Address o1h,
rj7JL�ZY[�'rl=ice
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
`-
Telephone No. PERMIT FEE $ v
(Signature of Owner or Agent)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass.. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone
F1am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing, workers' compensation for my employees working on this job.
Company name:
i.
Address
City Phone #:
Insurance Co Poles #
Company name:
Address
City Phone*
Insurance Co Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the -imposition of criminal penalties of a fine up to $1,500.00
andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature uate
Print name Phone #
Official use only do not write in this area to be completed by city or town official' Building Dept
[]Check if immediate response is required Building Dept 0 Licensing Board
0 Selectman's Office
Contact person: Phone #. 0 Health Department
O Other
FORM WORKMAN'S COMPENSATION