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Date ......�.`.:.�..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
............... w....DA-'Ui'�w ...... zi
has permission to perform........'.{......................../.........................................
wiring in the building of ...... .(�f, i.we G C
.....G ............. ...................
4-07-10
at .................................................... ................ , North Andover, Mass.
Lic. No....
� Fee ..................... v ,a'.'..3.00R.. ......... .� ..... ..... ..� .......
.. . ..... .....
5�,( ELECTRICAL INSPE R
Check N -3. l---
1 0444
Commonwealth of Massachusetts Official Use Only
Department ®f Fire'Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071
U94 1
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEA SE PRINT IN NK 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 pe
rfoim th e�ctrical work described below.
Location (Street & Number) lint /P /fio/%(j�a,J
Owner or Tenant 6,4 a ao// �' ,i/ l/e �- F Telephone No.
Owner's Address 34LV "O,B,a +Z)AJ4 ! 1 01 2?:Zq#1'' _ .
Is this permit in conjunction with a building permit? Yes [�r No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts
New Service _�4 Amps Volts
Overhead ❑ Undgrd
Overhead ❑ Undgrd
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work: 1A) 11-2-1 t 6
No. of Meters
No, of Meters /
Completion of the following table may be waived by the Inspector of Wires.
Recessed T n inai c
No. of __�__ss _ ,_Ln.._ _re 5/p
f C l e.. .a ), r
No. i/1 . Cell.-.�uSp. (Paddle), Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets /e
No. of Hot Tubs
Generators ICDA
No. of Luminaires
Swimming Pool Above ❑ Jia- ❑
nd. grnd.
IN o. of Emergency igting
Battery Units
No. of Recepiacle Outlets 1Dd
No. of Oi Burners
FIRS ALARMS
No. of Zones
No. of Switches .v
No. of Gas Burners
Ta1o..of Detection and
Initiating Devices
No. of Ranges /
No. of Air Coned. Total
Tons
No. of Alerting Devices '
g
No. of Waste Disposers /
Heat Pump
Totals:
l umber
....
Tons
"... .............
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers /
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
'Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
0.
No. of No. of
Signs Ballasts .
Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
.Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 suchcove ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [✓BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury, that Phe informal 7this application is true and complete.
FIRM NAME: EAJ L, % LIC. NO.: =Q 3g9 a
Licensee: Signature LTC. NO.: d_3FrQ-9-
(Ifapplicable, enter "exempt" in the license number line.) M _ 1L� Bus. Tel. No. 9;?,P R14_,,4 6 OV
Address: 4"b ern QOu� .L�Q.tJE ///cr..7 Alt. Tel. No.:
*Per M.G.L c.147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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/Auanf
The Commonwealth of Massachusetts
Department of Industrial Accidents
"VA
Office of Investigations
�a � 600 Washington Street
Boston, MA 02111
www.rizass govrdia .
Workers' Compensation Insurance Affidavit: B.uilders/Cont�rnctor°s&leotricians/Pln�bers
Applicant Information
Please Print LeQibl
Nan1e (Business/organization/lndividual):
Address:
City/State/Zip: Phone
Fampn employer? Check.the appropriate-box: '
•a employer with 4 Type of project (required):
�] I ama genera) contr]no
and Iloyees (full and/orpart-tune) have hired the sub-ctors S' ❑ New coristractiori.a.sole proprietor. or partner- listed on the attachet � �• ❑ Remodeling
and. have no employees These soli-contractoe ing for me in any capacity. workers' comp. insu$' ❑ Demoliti.orlorkers' camp. insurance 5. ❑ We are a corporationts 9, ❑ Building additionred ]officers have exercisir 10.0 Electrical repairs or additions
homeowner doing alt work right ofexemption pL 11.0 Plumbing repairs or additions
lf. [No•workers' comp. .c. t.52, § I (4); and weno �insurance-required.] t em to ees.12•❑ Roofrepairs
P Y [No workcomp. insurancarequ13.❑.Other
'Any applicant that checks bob#1 must also fill out the section below showing theirworkers' bompensation Policy information.
t f-lomeowners who submit this afii8avit Indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
- $Contractors that sheds this box mustr[tacf ed an Pdditional shset sho:vin$ Fho name of the sub oonhactor and their �verkars' carp pricy iron at=o„
1 arra e l9yer ghat is pyoviditlg:wor ItePs' co?, do
a arasurapace or a to ees: fed®ev is the olfc and 'ob si¢e
infortraatiom f y F Y !
Insurance Company Name: '
Policy # or Self-ins. Lic, #:
Expiration Date:
------------
Job Site Address:
Attach a copy of the workers' compensation lic declaration page (showing the policy number and expiration policy ptration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a-
fine up to.$1,500.00 and/or one-year imprisonment; as well as civil penalties in the faun ofa STOP WORK ORDER and a fine
Of up to $250,00 a day against•the violator. Be advised that a copy of this statement may f forwarded to the Office of
Investigations of the DIA for insurance coverage verin""cation.
! do hereby certify tinder the pains and penalties of perjury that the information provided afiove is true and correct:
Sienature:•
Date:
Phone #:
L[th
ttrtly. Do not w. rile L12 tris area, to be campletted by chy4 o; tvwh official
Town:
Permit/License #
ority (circle one):
health 2. Building Department 3. City/Town Clerk 4. Electrical In
5. Plumbing Inspector
on•
Phone #: