HomeMy WebLinkAboutElectrical Permit � ` l.ommoRrura�o`�� �Y�`T'' � _. .. 9�O�cia{Use Only /�
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BOARD OF FIRE PREVENTION RE - - r,- Oc ancy and Fee Checked
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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Ail work to be performed in accordance with the Massachusetts E(ectrical Code(ME�,527 CMR �2.pp
PLEASE PRINT IN INK OR TYPE ALL lNFORMATION) Date: l—D � �
City or Town of: ��jG�Jil7��- To the Inspector of Wires: �
� �B his application the undersign�ves nohce of his or her intrntlon to perform the electrical work described below. �
oQ,(`�L at[on(Street&Number) a 9� n,q�-f� �7 �
N� oer or Tenant /C� (/ �.. TelepAone Nw�o��3 y� — �!,
�*"' er's Address LA G-ffC1i� �J, G�p,.� � O�S,�j
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�s is permit iq conjunction with a bullding permit? Yes No Q�(Check Appropriate Box)
� � ose of Buildings/^'��c s��''Jit.�+ �U��o{ Utility Authoriza8on No. ��p� 6�� cf
�
ting Service dD Ampa / Z Y6Volb Over6ead �� Undgrd❑ No,of Meters Z-�
� ew Ser�!ce Amps / Volts Overhead� Undgrd � No.of Meten
Number of Feeders and Ampacity
Locatloa and Nature ot Proposed Electrical Work: jjJ/!� �'lG ��� y�..��,q�.�
/�/J� /�/�7�/�
Ca letron o !he o/lowin �able m be waived b the/ne ctor o Wires.
No.of Recessed Luminaires No.otCell.-Susp.(Paddle)Faos °•° o�
Transformers KVA
No.of Luminaire Outlets No,of Hot Tubs Generaton KVA
No.of Luminaire� Swimming Pool ove � n- � o.o mergency g ng
md. rnd Batte Unib
No.of Receptacle Outlets No.of Oil Burnen FIRE ALARMS No.ot Zoaer
No.of Switches No,of Gas Burnen . o.o etechon an
[niHatin Devices
No.of Ranges Na of Air Cood. Tona No,of Alerting Device�
rt`' No.of Waste Disposers eat mP ...um er,__ons.._._ ..._.._...._..._ o.o e ontsme
Totals: —� DetecHoNAlerHn Devtca
No.of Dishwashero SpacdArea HeaHng KW �ap� un c pal
� Connectlon � �'�
No,of Dryers Heating Applisnces K�y ( stems:*
o. of ater KW o.o 0 0 ° � •, � I�es or E uivalent
Heaters Si ns Ballas[s
� . . es .� ' nt
No. Hydromassage Bathtubs No.of i�lotors Total HP e1e0 �� �����,�' r
' "'` No.of Devices�b b �) t�'; i
OTHER: � ,,,, �
Arrach additiona!detoil ifJesired, o�as required by the Inspector oj9#ia�s.
yx� Estimated Value of Electrical Work: (When required by municipal policy.)
_: Work ro Start: 7—/�O� Inspections ro be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the perfortnance of elecuical work may issue unless
�: the licensee provides proof of liability insurance including"completed opetation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has e ibited proof of same to the pertnit issuing ofFce.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ Specify:)
!certify, under[he pains and pena!lies ofperjury,that the injor ation nrs lhis applico[ion rs true and complete.
FtRM NAME: /L�,� ,�(.,E(�fjZ(L
►.�c.rro.: r`��
Licensee•�6_t�i._/'�1 /^1 ,jiW-� �jrL Signature LIC.NO.: � Z�IL �I
- ("IJappficable,en(er "eze pl"in rhalicensenumber lrne.J us.Tel.No.: d��/Q�'Z
Address: �/.G�.l� /�- o ee m'J�o- a Zf L�
` Alt. Tel.No.:;0�07�
�' *Per M.G.L. c. 147,s. 57-61,security work requires Departmen ublic Safery"S"License: Lic. No.
OWNER'S INSURANCE WAIVER: [ am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. 1 am the(check one ❑ owner ❑owner's a ent.
OwnerlAgent
Signature Telephone No. PERMIT FEE: $