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u4r (goinilloilwalfli of NaBlia mutts Permit No.
13cpartment of Vublic eafctU Occupancy A Fee Checked
F PREVENTION REGULATIONS 527 CMR 12:00 1 3/90 (leave blank)
APPLIRMIT TO PERFORM ELECTRICAL WORK
All work to be peirforme accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TY E ALL INFORMATION) Date r Z-
City or Town of NORTH ANDOVER To the Inspector of Wires:
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' The udersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant 4-2 /, 1114Z*& 7-1/i
f Owner's Address
�! Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
j Existing Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps _. Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of eed sand Arnpacity ----- —"`!
1
Location and Nature of Proposed Electrical Work _-.Z _37, ,9 45-0 !�l¢7T/�D/�o�7r OLeTQOo�t
No. of Lighting Outlets No. of Hot Tu`5s No. of Transformer -.- Total_
KVA
No. of Lighting Fixtures Swimming Pool Above In-
grnd. ❑ grnd. ❑ KVA
Utoo rgency hting
No. of Receptacle Outlets No. of Oil Burners s
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
No. of Ranges No. of Air Cond. Total No. of Detection and
tons Initiating Devices
No. of Disposals No.of Heat Total Total
Pumps Tons KW No. of Sounding Devices
No. of Self Contained
No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices
No. of Dryers Heating Devices KW LocalMunicipal
❑ ❑Other
Connection
No. of No. of Low Voltage
No. of Water Heaters KW Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
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 ❑ NO ❑ 1
have submitted valid proof of same to the Office. YES ❑ NO ❑ It you have checked YES, please indicate the type of coverage by
checking the appr tate box.
INSURANCE QZ BOND ❑ OTHER ❑ (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work$
Work to Start2r3::::�-I— Inspection Date Requested: Rough Final ?—rY"
F115—
Signed under t Penalties of erjury: /
FIRM NAME �Y� QGT�t 2/t/L UC. NO.
Licensee 5// cA��K'!o -��Signatu N LIC. NO.
Address IF Z foe,,eZG Si • OW/ 1�P'u ITS BAIL. Tel. No. _.C-e 9 6 EJd SZIV
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent
(Please check one)
Telephone No. PERMIT.FEE $
(Signature of Owner or Agent)
X-6565
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