HomeMy WebLinkAboutElectrical Permit � ' �s� �,.,,« �,,. �,�,
- - The Commonu�eaIfh o,f Massachusefts �_�D_��
A�— r..:.. w.
� Deparnnrnt oJPub[ic Salety �/�e�
a����cr a r.e oK�ka
BOARD OF FlRE PREYENTION REGUlAT10NS 527 CMR 1290 3/90 ���,,,� e�,�k�
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Ail�wrk w bs perbrmed M�ccordance Wi�h tha Maacachuscm FJecuical Codc. 527 CMR 12:00 �
(pLEASE PRI23T ZH IHIC 0& TYPE ALL INFORHATION) Date � Y�
- City oi Tova of N/�.�.7a,�1'.6/ 2o.che Inspeewr of t7ires:
Ihe mdersigned applies for a permit to perfoxm�che electriul wrk dese qga� n
/0\ _ JI
Loution (Street 6 Humber) �' � ' /� A4c.9rarr�tlu
- Ovner or Ieoanc � O nf �..�
Ouner's Address � ,�i/? /J�S /��aJ� '—
� (Check Aovrooria[e x)
� Is ttiis permit in conjunetioa vith a Duilding permit: Yes ❑ No y
Purpose of Builpiny� $s^�� ��+�� Utility Autborization N0.
� Existing Servic! �/OD Acps ( 20 / liyu Volts Overhead .�Undgrd❑ No. o£ Heters/
:�'� Nev Serviee. Amps / Yolts Overhead ❑ Undgrd❑ No. of Tkte:s �
� N�mber of Feeders and Ampuity � �
� Loeation and Nature�of Proposed Eleetrical Work ��/r/f�y S�/'fK� �v�/� 'f
��
No. oE Lighti�g Outlecs No. of Hot iubs No. of izans£ormers Total
KVA
� No. of Lighting Fixtures . Swimoin Pool Above In-
�.- 8 grnd. � grnd. ❑ Cenerators KVA
� No, oF Reeeptaele Outlets No, of 031 Burners No. o£ Emergeney Lighcing
Batte Units
No. of Switch Outlets No. of Gas Burners FIRE ALARHS No. of Zones
. No. of Ranges No. of Air Cond. T��$ No. of Detection and
Initiating Deviees
�� No. of Disposals No. of �at$ Total Total No. of Sounding Deviees
T ns KW
� No. o£ Dishwashers Spaee/Area Hea[ing � NDeteetion/SoundingeDevices
�' ��� No. of Dryers Heating Devices � Loea1� ��neeCion❑0[her
No. o£ Water Heaters KH �. o£ o. o Low Voltage
Si s Ballasts Wirin
�Y
'�i No. Hydro Massage TuDs No. of Moeors Tofal HP
� O1lIER.
�.` INSURANC6 COVERAGE: Purauant to the requirements of Massaehusetts General Laws
I have a current Lia ility Insurance Poliey inaluding Completed Operations Coverage or i substantial
� equivalent. YES Q�NO� I have submitted valid proof of same to this offiee. YES�NO ❑
If you have checked YES� please indicate the [ype of coverage �y checking the appropriate box.
INSURANCE �OND ❑ Oif�R ❑ (Please Specify) L'JIM/KfKti��- (�iUL�J d Z��
g�: , piration ate
�.-� . Estimated Value of Electrical Work S ��JtO�� . ,/ . •L rL
Work to Start �!— —� Ins eetion Date Re uested: � Rou h — �a d Final r`r_a`�
Y � P 9 8 t'
� . Signed under che penalties of perjury:
i FIRM NAME �w�' JFi��lL . L.IC. NO.���
. Licensee �� l� -�WQ ��L Signature `�'�� LIC. N0.(�iL�L
Address /.SVX 0 d ,. ,Q�O Bus. Tel. No. — O
. Al[. Tel. No. f' Q �?B7�
OWNER'S INSURANCE HAIVER; I am avare that the Licensee does not have the insurance eoverage or Lts sub-
� scantial equivalent as requized Ey Massaehusetts General Laws, and that my signature on this pezmic
� - � application vaives this requirement. Owner Agent (Please cheek one) .
� - Telephone No. YERMIT FEE S
SignaWre of Ouner or Agent -