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Date./Q.A..f�
q
I .. .3.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that.....................
........ .............................................................
has permission to perform ... c. ...... 1�'�kk ........................................
wiring in the building of ..... // .........................................................
at ... ///.// ..... .................. . North Andover, Mass.
Fee... Lic. NoA.. .................... V ............ P ...............
ELE 6-RICAL INSPECTOR
Check # 1?2 31?
48'11
coommnweawi of massachusetts Othcial Use Only
Department of Fire Services Permit No. /
\VJ1 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 11/99] leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 1200
(PLEASE PRINTW INK OR TYPE ALL INFORNL4TI0h) Date: la — Y —
City or Town of /i/¢y,Q�� 1 To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perfo a electrical work described below.
Location (Street & Number) rr , !/ / -r Sv �vn /
Owner or Tenant (j -e , Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building �,.�� //_ < Utility Authorization No.
Existing Service -#, Amps Volts verhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Ruracn ada:tionai detail ij desired, or as required by the Inspector of Tyires.
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:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start:/v'?- --r- -7/ ? Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
Licensee: oll,,
(If applicable, e�r "exempt" in the license number line.) V
Address: G t
OWNER'S INSURANCE WAIVER: I am aware that the Licensee dods
required by law. By my signature below, I hereby waive this requirement.
Owner/Agent
Signature Telephone No.
LIC. NO.:�yy3�
�. LIC. ��N--O. ;P 3
Bus. T�7No.• -zea
r Alt. Tel. No.:
nat have the liability insurance coverage normally
I am the (check one) ❑ owner ❑ owner's anent.
PERMIT FEE: S
�=.ciavn yr lr{G iu"u"n
iuo'e rnav oe walvea ov the lnsvector of Wires.
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No, of Lighting Futures Z
Swimmin Pool Above ❑ In- ❑
g
i o. o mergency ig ting
arnd. end.
Battery Units
No. of Receptacle Outlets /V
No. of Oil Burners
FIRE ALARMS
[No. of Zones
No. of Switches
No. of Gas Burners
�No. -of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump
i umber
ons KW
o. of Self- ontained
Totals:
Detection/Alertin Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
1 0. of Water
No. of i o. of
No. of Devices or Equivalent
Heaters KW
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total B?
TelecommunicationsWiring:
No. of Devices or E uivalent
OTHER:
Ruracn ada:tionai detail ij desired, or as required by the Inspector of Tyires.
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:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start:/v'?- --r- -7/ ? Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:
Licensee: oll,,
(If applicable, e�r "exempt" in the license number line.) V
Address: G t
OWNER'S INSURANCE WAIVER: I am aware that the Licensee dods
required by law. By my signature below, I hereby waive this requirement.
Owner/Agent
Signature Telephone No.
LIC. NO.:�yy3�
�. LIC. ��N--O. ;P 3
Bus. T�7No.• -zea
r Alt. Tel. No.:
nat have the liability insurance coverage normally
I am the (check one) ❑ owner ❑ owner's anent.
PERMIT FEE: S