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BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Office Use Only 1
Permit No_ 1 K I
Occupancy & Fee Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information)
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number '5( I "i 'e ✓ e r (y
Owner a
Owner's
Date__IL
To the Inspector of Wires:
Is this permit in conjunction with a building permit Yes ❑ No � (Check Appropriate Box)
Purpose of Building 2- P /9M 1 Utility Authorization No.
Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters
New Service -Am s Volts Overhead ❑ Undgmd ❑ No. of Meters
Number of Feeders and Ampacity n
Location and Nature of Proposed Electrical Work / % J4 ed r fM 2- A ��
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a curets Liability Insurance Policy including Completed Operations Coverage or its substantial equivalentYES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type rage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify)
�� (Expiration Date)
Estimated Value of Electrical $ l7 /) /, /
Work to Start = ' - ! Wo tInspection Date Resquested Rough Final //��
Signed underthe Pen es of perjury:
FIRM NAME -14 LM LIC. NO.
Licenses ?J9 L%% lT+ e? ;o P7 Signature LIC. NO. �
�) Bus. Tel No. (0 D J
Address / �� � �%� Y i f + /IIx ILV9 i Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Ma achusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) \
Telephone No. PERMIT F
(Signature of Owner or Agent)
Total
No. of Ught8ng Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑
In ❑
No. of Lighting Fixtures
Swimming Pool gmd G
gmd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Bumers
FIRE ALARMS No. of Zane
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Di sal
No. Pumps
Tons
KW
No. of Sounding Devices
No./ of Seif Contained
No. of Dishwashers
Soace/Area Hearing
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heatinq Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a curets Liability Insurance Policy including Completed Operations Coverage or its substantial equivalentYES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type rage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify)
�� (Expiration Date)
Estimated Value of Electrical $ l7 /) /, /
Work to Start = ' - ! Wo tInspection Date Resquested Rough Final //��
Signed underthe Pen es of perjury:
FIRM NAME -14 LM LIC. NO.
Licenses ?J9 L%% lT+ e? ;o P7 Signature LIC. NO. �
�) Bus. Tel No. (0 D J
Address / �� � �%� Y i f + /IIx ILV9 i Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Ma achusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) \
Telephone No. PERMIT F
(Signature of Owner or Agent)
No-
" I J Date .... J 7�/... D
TOWN OF NORTH ANDOVER
' PERMIT FOR WIRING
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This certifies that tAl lw; ....i �,—
has permission to perform .......Q......e1 :t t n ...........................
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wiring in the building of ..... ��t S:e.E: - .Q. ......................................... s
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at ..... �C C� .... F..u...: f.. f . t ........................... . North Andover, Mass. o
Fee. 4.. Lic. No. ........ AL .. INS.P..E...C.....R................
ELECTRICTO
C��77
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer