HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMIT TO PERF�i�RM ELECTRICAL WORK
rVl work co be perfnrmed in acmrdance with rhe Massac6useccs Eleancal Code,'(MEC), 527 CMR 12.00
�? � r4Q'� (OFFICE USE ONLV)
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� TOWN OF Y � v �
� ee: $� �C s�
��( � �N 2 5 U4 ERMIr1�Q��1��
(PLEASE PRINT'IN INK OR TYPE ALL IN TION`� �a�[J•� Date: y"O
To the Inspector of Wires: By this applicalio d'gf�C� no ice of his or her intention to perform the electrical �
work described below.
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I.ocation (Street&Number� �o� /Y—�l�—�'�1�- �E� � � �
OwnerorTenant_ ��Q�Y /�� � I C,�S Tele on�,p� �
Owner'sAddress u�'��e y
HEALTH DEPT. �
Is this permit in conjuncrion with a building permit7 ❑Yes ❑No (Check Appropriate Box �
Purpose of Building Utility Authoris arion No.
�
Existing Service �� ,a,mps /o�� /� Volts Overhead� Und "L
grd❑ No. of Meters_�_�
New Service Amps— / Volts Overhead� Undgrd Q No. of Meters
Number of Feeders and AmpaciTy `{�
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I.ocation and Nature of Proposed electrical Work:—���i� J�C�Q SYS�/!�1 �
\
� Co letlon the olfmvirtgtablema bewarvedb rhe[ns ectorofWiresa
� ,l o. of essed Fixtures [Qo.of Total �
. of Ceil.- s . addle Fans Transformers KVA
No. of Li tin puflets No. of Hot Tubs Crenerarors KVA
No. of Li tin Fixtures Above n- No, of Emergency Lighting
Swimmin Pool d. ❑ md. ❑ Batte IInirs
No. of Receptacle Ouflets No. of Oil Bumers FTRE ALARMS No. of Zones �'
No. of Switches No,of Gas Bumers N��IninaDun D�evices
No. of Ranges No. of Air Cond. Total
Tons No. of Alerting Devices
No. of Waste Disposers HeSt T�u�m�. umber ons __ _No. of Self-Contained
Q Detec[iou/Alertin Devices
� No. of Dishwashers Space/Area Heating KW �o�� � Municipat
No. of Dryers Heaung Appliances I�VV S�tiry Systems:Connecuon ❑ �her
`Q No. of Water No, of No. of Devices or E ui valent
Heaters gW No. of p�µr�g:
Si ns Ballasts No.of Devices or Equivalent
� No. Hydtomassage Bathtubs No. of Motors Total HP Telecommunicatlons Wiring:
� No.of Devices or E uivalenr
�^ Aa¢ch additional detail if desired, or ar required by the Inspector of Wires.
„�y INSURANCE COVERAGE: Unless waived by t6e owner, oo peimit for the perFormance of elecn ical work may be issued unless the lice¢see provides
LJ proof of liability insurance includiug "completed operafion" coverage or iu substandal equivalen�. 1'he undenigued cetU};es that such covuage is in
force, and Las ezhibited proof of same m[he permit issuing office.
CHECK ONE: INSURANCE � soivnQ rn•�x� csp�;ry:� j�-,�9,PVC Fil/yqGY /�5
�Estimated Value of Electncal Wotk; �"'atiO/��)
Work to Start: (�'lien required ty manicipal policyJ
Inspecaons to be reguested in accordance wit6 MEC Rule 10, and upon completion.
�I certify,undeL�C pa�ins �ge of erjury that the inforniation on this applicaaoi�is tme and complete.
� FIRM NAME: .{?Y�'/ �I�fl� �E�.e( �/�M LIC. NO. E.3/S'�'
wLicensee: Signature LIC. NO.
(!f applica e, e er "exem t" in H�e lic nse u bqr�line.) Bus. Tel. No,: —
Address• DC�O ci�r Alt. Tel. No.: S� ��
� OWNER'S INSURANCE W,4IyEg;I am awere that ihe Licensee does not have the liability insuraz�ce coverage normally iequ'ved by law.By my signature
� below,I hereby waive this requiremenL I am the(check one)owner Q owner's agent.�
� Owuer/Agent
Signature Telephore No.