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Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Date Issued:,____
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5110110
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) Salem St Station Map: Lot:
Owner or Tenant North Andover Fire Department Telephone No.
Owner's Address Town of North Andover
Is this permit in conjunction with a building permit? Yes 0 No Z (Check Appropriate Box)
Purpose of Building Fire Station Utility Authorization No.
Existing Service Amps Volts OverheadF] UndgrdF1 No.of Meters
New Service Amps Volts OverheadF-1 Undgrd F-1 No. of Meters
Number of Feeders and Ampacity same
Location and Nature of Proposed Electrical Work: Front of building wiring for generator
Completion of thefiollowing table may be waived by the Inspector oJWires.
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 Ei In- F� No.of Emergency Lighting
No.of Lighting Fixtures Swimming Pool
grnd. ❑ grnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pum Number K o.of Self-Contained
Total:
Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local r-1 Municipal EJ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Illydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER: Wiring of 50-Kw generator I
Attach additional detail if desired, or as required by the Inspector of Wires.
,Estimated Value of Electrical Work: $2100.00 (When required by municipal policy.)
Work to Start: 5/12/10 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 licen-
see 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 it issuing office.
CHECK ONE: INSURANCE Z BOND F-1 OTHER F-1 (S "ify:)
, at ,
I certify,under the pains and penalties of perjury,that lice infor 'anon on this application is true and complete.
FIRM NAME: Andover Electric Services, Inc LIC. NO.: 14302
nat
Licensee: Robert J. Branca Sig *�t LIC.NO.:
*Per M.G.L. c. 147,s. 57-61,security work requires Depa nt of Public Safety"S"License: LIC.NO.: S:
(If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 978-475-4995
Address: 19 Dale St Andover, MA Zip: 01810 Alt.Tel.No.: 978-423-8350
OWNER'S INSURANCE WAIVER: I am aware that the Ucensce does not have the liability insurance coverage normally required bylaw. By my
signature below,I hereby waive this requirement. I am the(check one)D owner El owner's agent. Permit Fee:
Owncr/Agent Signature Phone:--.-- I