HomeMy WebLinkAboutInsurance Letter - Permits #11502 - 18 COPLEY CIRCLE 4/8/2013 �y
Date.............................................
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fir; .'• 04 TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
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This certifies that
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has permission to perform j ��
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wiring in the building of..................... :...................
at ..` .. �..5 9 ... . ' .,North Andover,Mass.
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Fee .... .....Lic No}�.. ... .. . 2:............ .. '..��,' . ...... �`. �.f �. ..k. .s.,�, ,
ELECTRICAL INSPECTOR
Check#
Commonwealth of Massachusetts Official Use Only
Department of ,�L'/`V/Fire CGS Permit No.
' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (leaveblan10.
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All world to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL.INFORMATION) Date:
City or Town:of: NORTH ANDOVER To the Inspector of Wires:
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 /6 (� %,�%j /``%/� Telephone No. '� C
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box)
Purpose of Buildin Utility Authorization No.
- Existing Service Amps % J / - OIts Overhead ❑ Undgrd No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table maybe waived by the Inspector of Wires.
No.of Recessed Luminaires _No.of Cell:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlet No.of Hot Tubs Generators KVA
Above In- o.o mergency ig tmg
No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batt Units
No.of Receptacle Outlets No.of Oil Burners F ALARMS No. of Zones
No.of Switches No.of Gas Burners o.of Detection and
Initiatin Devices _
Total
No. of Ranges No.of Air Con Tons No.of Alerting Devices
No.of Self-Co
No.of WasteDispo s HeaT tm p ,.umber Tons,.., ,.... ............... Detection/Alerting ices
No.of Dish ers Spa Area Heating K Local❑ Conneipion ❑ Other
No.of Dryers eating Appliances Security Syst , s:'
y KW No.of ices or E uivalent
No.of Water K No.of No.of Data W' ing:
Heaters Signs Ballasts No. f Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Te)Nommueviceio r Wiring:
No.of Devices or Equivalent
OTHER: lel
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical ork: t' - J, (When required by municipal policy.)
Work to Start: a�"`' Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: 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 El (Specify:)
I certify, under titepaitts and penalties ofpeijury,drat the information on this application is true and complete.
FIRM NAME: . �' /411A,1-' AV/V 1%�S 4 TAtX LIC.NO.: r�
Licensee: IvIAC'IAWI) Signature LIC.NO.:
(If applicable,enter "exempt"in the license number lin .) Bus.Tel.No.:t` r2 `� ,
Address: ZZ/ce-, I T % � r ''7�/'rf ll��f� I Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the 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/Agent PERMIT W. $
Signature __ Telephone No.