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WRIS in The Commonwealth of Massachusetts Office Use Only
Permit No.
Department of Public Safety
F� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Fee Checked'
3190 (leave blank
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordant with the MassachMtla Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date_
�Z 7
City or Town of—i1�P To the Inspector of Wires:
The undersigned applies for a Ocf' .it to perform the electrical work described below.
Location (Street & Number) o ✓ i
Owner or Tenant 2 0 OA/M V `�% % O&Z
Owner's Address 7 0 C G RATA oh E 4 1� / ,61- " , L' 0 W
Is this permit in conjunction with a building permit yes ❑ no ❑ (Ch �;k Appropriate Box)
Purpose of Bui
Existing Service Amps / Volts
Utility Authorization No
New Service Amps / Volts
Number of Feeders and Ampacity
/'
Location and Nat- a of Proposed Electrical
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance POlio including Completed Operations Coverage or its substantial equivalent. YES CX NO ❑ 1 heave submitted
valid proof of same to this office. YES NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE P9 BOND ❑ OTHER ❑ (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work $
Work to Start
Signed under the penalties of perjury:
FIRM NAME CITY WIDE ETEC
Licensee ANTHONY' LEMIRE
AAA—. 4 JACKSON DRIVE,
Inspection Date Requested:
Signature_
HUDSON, NH 03951
Rough $ Final
LIC. NO. 578 -HR
LIC. NO. 16650E
Bus. tel. No. 603/886-9640
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by
Massachusetts General Laws, and that my signature on this application waives this requirement. Owner Agent (Please check one)
Telephone No. PEHMIT FEE $
(Signature of Owner or Agent)
i
TOTAL
No. of lighting Outlets
No. of Hot Tubs
No. of Transformers KVA
AboveIn
❑ ❑
No. of Lighting Fixtures
SwimmingPool rnd. rnd
Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
TOTAL
No. of Ranges
No. of Air Conditioners TONS
Initiating Devices
No. of Sounding Devices
HEAT TOTAL TOTAL
No. of Disposals
No. of Pumps TONS KW
No, of Self Contained
Detection/Sounding Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
❑ ❑
No. of Dryers
Heating Devices KW
Local Connection Other
No. of No. of
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. of 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 POlio including Completed Operations Coverage or its substantial equivalent. YES CX NO ❑ 1 heave submitted
valid proof of same to this office. YES NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE P9 BOND ❑ OTHER ❑ (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work $
Work to Start
Signed under the penalties of perjury:
FIRM NAME CITY WIDE ETEC
Licensee ANTHONY' LEMIRE
AAA—. 4 JACKSON DRIVE,
Inspection Date Requested:
Signature_
HUDSON, NH 03951
Rough $ Final
LIC. NO. 578 -HR
LIC. NO. 16650E
Bus. tel. No. 603/886-9640
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by
Massachusetts General Laws, and that my signature on this application waives this requirement. Owner Agent (Please check one)
Telephone No. PEHMIT FEE $
(Signature of Owner or Agent)
i
Date z � ..... ,
TOWN OF NORTH ANDOVER A
PERMIT FOR WIRING a
8
This certifies that ......4..--M, •cry ...... .... ..............
has permission to perform ...".:!. cam!.. .....:'`�:
wiring in the building of - -1 .,.::-..�...,... �,{ :......` .......................
/ cru
at ...1.l` .`: L ............................ . North Andover, Mass
Fee..................... Lic. No.............................................................................
c6l
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer