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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that,.,.:...........G..................................................
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has permission to perform
wiring in the building of ..,.. `..:...?-?...............
at AA01t ..��J� c�
............................. ,North Andover, Mass.
Fee ...t ............. Lic. Nor,
ELECTRICALINSPECTOR�
Check # \(//
6G5>4
TRE COMMOATH ALTHOFMASSACHUSETTS
DEPAITW7'0FPUBLICS4FETY
BOAROOFFIREPREVE MONRF.GUTA770NS527CMR I2.-1
Y�V
Office Use only
Permit No. 611( �
Occupancy & Fees Checked
APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK 17"
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
itl
Is this permit in conjunction with a building permit: Yes t;1
No (Check Appropriate Box)
Purpose of Building Poo 1 J V Utility Authorization No.
Existing Service Amps / Volts OverheadUnderground r-1No. of Meters
New Service Amps / Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work t l S7 777 D ,
No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total
TH;
mance^overage PuMlatttothe taquitementsofMassachusctsGerfalLaws
ave aam it Liability h>StuancePblicyinchxingComplelp Cove ageoritssubstantialequivalent
avesubnmWdvalidproo fsmrtotbeOfiiw YFS
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SURANCE BOND OITUR F1 (Please Spetafy)
YES El NO
EsU►mted Vahrofflearical Wdk $
xktostart kgectionDateRecps(ed Rough Final _
nedurderTrFt Aesof I r+ -i_ l
:MNAME LioffmNo.
msee S7oyt' tJU�,o Sigretur: _ Licer&No
n Busir�sTelNo. 92 6 kJ-H3
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AIt TeLNo.
ggR'SINSURANCEWAIVER;lam a that d -e I icmg-- does nothave the iranncecoveragcorits substantial equivalent as required byNiassafts2nGerier Lam
that my signature on this peanit application waives this ragmeinent
:ase check one) Owner® Agent
Telephone No. PERiVITT FEE $ "7V
Signature or Owner or Agent
1%. VA
No. of Lighting Fixtures
Swimming Pool
Above
Below
Generators
KVA
round
ground
No. of Receptacle Outlets
No. of Oil Burners
No_ of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
No. of Ranges
No. of Air Cond.
Total
FIRE ALARMS
No. of Zones
No. of Uri osals
No. of Heat
Tons
Total
Total
No. of Detection and
Pumps
Tons
KW
Initiating Devices
No. of Dishwashers
Space Area Heating
KW
Nq. of Sounding Devices
N,;:,oESelf Contained
Detection/Sounding Devices
No. of Dryers
Heating Devices
KW
Local Municipal
Other
Connections
No. of Water Heaters KW
No. of
No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
TH;
mance^overage PuMlatttothe taquitementsofMassachusctsGerfalLaws
ave aam it Liability h>StuancePblicyinchxingComplelp Cove ageoritssubstantialequivalent
avesubnmWdvalidproo fsmrtotbeOfiiw YFS
�g the x
SURANCE BOND OITUR F1 (Please Spetafy)
YES El NO
EsU►mted Vahrofflearical Wdk $
xktostart kgectionDateRecps(ed Rough Final _
nedurderTrFt Aesof I r+ -i_ l
:MNAME LioffmNo.
msee S7oyt' tJU�,o Sigretur: _ Licer&No
n Busir�sTelNo. 92 6 kJ-H3
l�Wti G
/V6,
AIt TeLNo.
ggR'SINSURANCEWAIVER;lam a that d -e I icmg-- does nothave the iranncecoveragcorits substantial equivalent as required byNiassafts2nGerier Lam
that my signature on this peanit application waives this ragmeinent
:ase check one) Owner® Agent
Telephone No. PERiVITT FEE $ "7V
Signature or Owner or Agent
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigation
Boston, Mass. 02119
Workers' Compensation insurance Affidavit
Name Please Print
Name:,.,'I
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance Co. Policy #
Company name:
Address
City: Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' imprisonment_as wetLas_civil..penaltiesinlheformnfa..STOP WORK_ORDER.and_a.fine.of_(.$1,00..OD)_a dayagainst..me.
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone *
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
❑Check if immediate response is required Q Licensing Board
Selectman's Office
Contact person: Phone #: Health Department
Other
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