HomeMy WebLinkAboutElectrical Permit -- -
�"� Oltice Use Only�
! ,� LI1C L11111IntiIllUfc�jtll I1� �c�aSc�Lh1I5Ftt5 Pe�mit No.
. f��.rp.ut�ncnt nf �lublic �afct� Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 5�92 <leave blank)
�
APPL1CATiON FOR PERMIT TO PERFORM E�ECTRICAL WORK
a All work to be performed in accordance with ihe Massachusetts Elecirical Code. 527 CMR 12:00
a (PLEASE PRINT IN INK OR TYPF.� ALL INFORMATtONj '�pate...,_ �- _
,,n City or Town ot �� -����--� th ecto�t W' '
� The udersig�ed applies for a permit to periorm the electrical work described w.
�ocation (Street 8� tvumber) �V' -� APR
wW
Owner or Tenant � � T •
Owner's Address �"J�l Tel�" ,
A A .
Is this permit in conjunction witFl a building permit: Yes ❑ No � (CheCk Appropriate BOx)
Purpose ot Building Utility Authorization No.
Existing Service l� Amps U Z�'Volts Overhead � Undg�nd ❑ No. ot Meters r
' z W New Service Amps � �`Volts Overhead ❑ Undgmd ❑ � No. ot Meters_
w w Number of Feeders and Ampacity
Location and t�wre of Propo ed �ieccrical Work � ��cJ� � � (��.J'� �U
ww
d d � ' N ' 'o'
A A No. of Lighting Outtets No. of Hot Tubs No.ot Transtormers ���
• KVA
No.of Lighting �xlures Swimming Pool �° ��'
g��d. ❑ gmd. ❑ Genarators KVA
� No.ot Emergency Lighting
No. of Receptacle Outleu No. ol Oil Burners Baqery Units
No.of Switches . No.of Gas Burners FIRE ALARMS No.c>f Zones
W W
H H No. ot Ranges No. ol Air Cond. Total No.�Oatection and
3 � to�s Initiating Devius
a � No. of Oisposals No.ol Pumps Tons KW No.of Sounding Owiees
No.of Self Contairwd
No,ot pishwashers Space/Area Heating KW DeteetioNSounding Oevices
A
a No. of Dryers Heating Oevices Kyy �� Munieipal Other
N ❑ Co�nection ❑
� No.ol No.of �ow Voltags
W No. ot Water Heaters KVN Signs Ballasts Wi�ing
C4
, y, No. Hydro Massage Tubs No.of Motors ToW HP SeCurity System
+ „~j OTHEA:
i � ~
i � = INSURANCE COVEAAGE: Pursuant to the requiremems ot•MassacAusetts general laws
� have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O NO O �
I � = have submitted valid proof ot same to the OHiee. YES O NO ❑ If you have cheeked YES, please indicale the type of eovenge by
I �
checking the ap r priale b�c.
i C� E INSURANCE �BONO O OTHER O (Please Specily) '
(Expiratlon Date)
; � 3 CHECK APPROPRIATE BOX: I have Worker's Compensation Insurance `� I have no Employees ❑
i r"' ' l
"'� Estimated Value ot Electrical Work S�U' �
I �� WOrk t0 Sldr1 , � �� ' �,�
Inspection Date Requested: Rough f' Final
� s. Signed under the Penalties o1 p ry'ury:
" 32.��'r '�
V � FIRM NAME C < l ' /�C/I N UC. NO. �'
���\� Ucensee � Signawre - �' �-�' UC. NO.,�72 Lw=� �
x �,j� (�
Bus.Tel. No.
'� Address IC/i �f \w (!� c��'�r )C.�1� t, i
Alt. Tel. No. '�/
:.7 r�--C+-�--F' � —+
. �,��� OWNER'S INSUfaANCE WAIVER: 1 am aware that the Lice�see does not have the insurance cwerage or us suOstanUal eqwvalent as re-
;� quiretl by Massaehusetts General l.aws, a�d ihat my signature on this permit application waives this requirement. Ownet f►9em
. (Please cheek one)
Telephone No PERMIT FEE S
(Signawre ol Owner or Agenq