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� j The Commonwealth of Massachusetts Perritt No.
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Dcpar•tnlent of Public Safety 3/90 (lasve blank) �(,
'\ BOARD OF FIRE PREVENTION REGULl fl7 CMR 121010
APIDLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perb)rme i In accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE ]'Rl'NT IN INE: OF. 'CYPE ALL INFORHAT.I011) Date 9A; lei 7
City or Town of 1% 40JO A, — To the Inspector of Wires:
The undersigned applies for a permit t�o� perform the e-l�e__c``trical work described below:
Location (Street & Number) ,Q!— �d
Os-ner or Tenant Tk7Ov , C,L, f
Ouaier's Address
Is this permit in conjunction -oith a building permit: Yes ® No ❑ (Check Appro elate Box)
Turpose o.1: Building �CI ) Utility Authorization(Che
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Existing Service —Arps__ / Volts Overhead ® Undgrd❑ No. of Neter
New Scrvi<:e A ns_ �*W / Volts Overhead [9 Undgrd❑ No. of Meters &L
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of Feeders and Ampacity__ ��teGf2! /U441
Locat•on and Nature of Fropn.sc d Electrical Work
ev_ yvIAZ.'L e. w
No. of Lighting Outlets I— No. of Hot Tubs No. of Transformers Total
� _ _ KVA
No, of Lighting Fixtures Swimming Pool Above El grnIn-d. 1:1grnd. Generators xvA
z _---
c No. c` P.ecertacle Outlet-. a No. of Oil Burners No. of Emergency Lighting y
Battery Units ems`
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No. of Switch s � No. of Cas Burners FIRE ALARMS No. of Zones
No. of Detection and
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No. of Ranges No. of Air Cond. Tions
o _ --_— Initiating Devices
No. of Disposals No. of Pumps Total Total g
No, of Sounding Devices
m --- Tons KW
JNo. of Self Contained
D No. of Dishwashers Space/Area Heating KW
c Detection/Sounding Devices
N0, or Prvcrs Heating Devices �, l:W Local❑ Municipal [—]Other- - _ Connection
--- --- - No, of No. of Low Voltage
No. of Water Heaters t;w Sj ns Ballasts Wiring
o ?do. H}'dro Massage Tubs No. of Motors Tota) HP 1
OTHER: G :�,SS v S 4c> e�K.tSf -Rv4-0 J"&AryN
INSUFANCE COVERAGE: Pursuart to the t'equi.rements of. M.,ssachusetts General Laws
I have a current Liability Irsurance Policy including Completed Operations Coverage or its substantial
equivalent. YES[L NO ❑ 1 have 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 BOND OTHER ❑ (Please Specify)_
0 t�t?� (Expiration
Estimated Value of Electrical. Work $ . 1 rate
Work to Start Inspection Date Requested: Rough(J`IIC�I Final _
Signed under the penalties of perjury:'
FIRM NAME 1t4ci, � LIC..Nn.
Licensee —Signature V'NO.
Address / L� �� us No.
Alt. Tel. No.
OWNER'S INSURANCE WAIVER• I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this pe it
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEES
Signature of Owner or Agent
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Date....... ... `
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�,SSACMU`�ES
This certifies that ......!.I!L...... .
.......... .......................................................
has permission to perform ...... d �ctfl` ..
Wiring in the building of.......r6wo..........CO. a....
at..... ........a...... �C'R..tY........t` .�............. ,North Andover,Mass.
Fee..Uo..!O Lic.No. Ls'/..�!.�...............................................................
ELECTRICAL INSPECTOR
C 08/27/97 11:50 250.04 PAID
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
'SOWN Or"'GRI'll ANDOVER ORTH
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OBSERVATIONS,
GOOD CONDI'llON
HEAVY(jpCME
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Exczssive Soum�---- L 'ACl[F'B'-JD RUNBACK
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SOLID CARRYOVE"ll'— (--YrHER EXPLAIN
SYSTEM- PUMPED By
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RANSVEMED J�0 1