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210/046.0-0096-0019.0
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Date.��..:.%..`......�............
f NORTH 4
TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
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This certifies that .....................�.: ?:..IBJ...................................................
has permission to perform .... ...
,wiring in the building of '
at............................. ................ .............. ,North Andover,Mass.
`IFee..................... Lic.No.............. ... ......�.. �................................
..
ELECCRICALINSPECTOR
Check # ��-'�
4. 47 :3
Gofiiitris:rfl,+ec:nn of t�l���ua:rraa��ec3
Permit No. _
` Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massadiusetts Electrical Code(MEC),527 CMR 12.00
LEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of• or heTo the Inspector of Wires:
y
By this application the undersigned gives otice of hi� r intention to perform the electrical work described below.
Location(Street& Number) VI
Owner or Tenant L. L -
12-1
Telephone No. -J'
Owner's Address o .0 e
9,116 1
Is this permit in conjgnction with a building permit? Yes ❑ No (Check Appropriate Bos)
Purpose of Building c WC) Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No. of Meters
NewSery .ice Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
�v e
--�--c—
Completion of the following table may be waived by the Inspector of Wires.
No.of Total
No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans Transformers KVA
No.of Lighting Outlets No.of Hot Tubs
Generators KVA
Above In- o.o Emergency Lighting
No.of Lighting Fixtures Swimming Pool rnd ❑ rnd. ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Detection and
No.of Switches No.of Gas Burners Initiatin2 Devices
No. of Air Cond. Total No.of Alerting Devices
No.of Ranges Tons
Heat Pump 14umber Tons KW No.of Self-Contained
No.of Waste Disposers Totals: Detection/Alertina Devices
unic
L
No.of Dishwashers Space/Area Heating KW Local ❑ Connection ❑ Other
Heating Appliances KW Security SyYstems:
No. of Dryers No.of-Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or E uivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
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 such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)4����v7?,W t
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: inspections to be requested in accordance with NEC Rule 10,and upon completion.
1 certify, under the pains and penalties of perjury,that the information on this application is true and complete
FIRM NAME: LIC.NO.:
Licensee: o�/ r�X Signatu LIC.NO.-J
(If applicable, ter " Bus.TC
avempt"in the license number line.) L No.' yG' - ���
Address: F/c .,�� S��a �vrt/ IYV�.- _ Alt.TeL No.• "a f
OWNER'S INSURANCE WAIVER: I am aware t t 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 a ent.
Owner/Agent PERMIT FEE. $�V
Signature Telephone No.