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Office Use Only
Permit Na �7�� 22.`•�
'%s�£ �,t�l�ik/l�.•L' y%i.S.S1¢(.S`i�.5 Occupancy & Fee Checked
Dream Pa6l[e Satiety
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527aCM 12:
1 93'
(Please Print in ink or type all information) Date
To the Ins ecto of Wires:
Town of North Andover
The undersigned applies for a permit to perform the eie:tncal work
Location (Street & Number.
Owner or
Owner's Address x
Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box)
Purpose of Building Ublity Authorization No.
Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters
New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts ssachusetts General Laws
I have a current UablW Insurance Policy including Co eted Operations Coverage or its substantial equivalent YES NO =
have submitted gird proof of same to the Office YES"-- NO = If you have checked YES please indicate the type of c age by checking the appropriate box
INSURANCEV BOND = OTHER = (Please Specify) /1166
(Expir on ate)
Estimated Value of Electrical Work$ /4'n') d`'
Work to Start inspection Date Resquested Rough Final
Signed under the Penalties of perjury:
FIRM NAME LIC. NO. j
Licensee CO Signaba ` LIC. NO.IA`?
A 1 ` Bus. Tel No.
Address G • ���-sI�•-Y r �<<� P 2 (�' /y �( Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licens6sdoes not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $�
(Signature of Owner or Agent)
Total
No. of Light8nq Outlets
No. of Hot fuse
No. of Transformers INA
Above ❑
In ❑
No. of Lighting Fixtures
Swimmin Pool and 13and
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Sumers
FIRE ALARMS No. of Zane
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices .
Heat Total Total
No. of Di al
No. Pumps
Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
S ace/Area Heating
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heatinq Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts ssachusetts General Laws
I have a current UablW Insurance Policy including Co eted Operations Coverage or its substantial equivalent YES NO =
have submitted gird proof of same to the Office YES"-- NO = If you have checked YES please indicate the type of c age by checking the appropriate box
INSURANCEV BOND = OTHER = (Please Specify) /1166
(Expir on ate)
Estimated Value of Electrical Work$ /4'n') d`'
Work to Start inspection Date Resquested Rough Final
Signed under the Penalties of perjury:
FIRM NAME LIC. NO. j
Licensee CO Signaba ` LIC. NO.IA`?
A 1 ` Bus. Tel No.
Address G • ���-sI�•-Y r �<<� P 2 (�' /y �( Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licens6sdoes not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $�
(Signature of Owner or Agent)
COMMONWEALTH OF MASSACHUST7
kif
iDIVISION OF REGISTRATION
OF ELECTRICIANS
bs�tCTRIG�
AS A REC�S RMFst
ALTON W HITCHCOCK
c.
P 0 BOX 285
DERRY NH 0303$-028,.
790JR 07/31/99
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