Electrical Permit i � • ��"!
a .
., Commonwealth of oR��u�on,y
� Massachusetts P`�"`N°. B�°�-,s-oa�r�a
; BOARD OF Fi[tE PREVENTION REGULATIONS Oocupan�.y�ad Fee Chockcd •
Rev.l AD'f
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AI�,.�ak�o be p«wm�ea in.o�d�a w;�n ihe M�nuoetts Elaaial caae cMEc�.s2T cMR�Z.00
(PL6ASEPRlNTlNINK OR TYPEALL/NF70RM�lTION� Ditt:1 H 2/'2015 •
� Chy or Tows oi: YARMOUTH roY,r�ie�euarq�w�,rs:
f Sy fhis applicatian the undersi�ed�iva • o ot cc • wak deacn'bed below.
i� Loestbn(Street i�Ti�mbe�) 200 SPRINGER W
1 �r�er o�1'sdsat ROSENBLATI'/WN LESUE TRS Tekp6o�e Na
i Ow�er�Addrw STARR B,H,IMOLFF S,SPAJN M, 98 FiAT1i8UN RD,w►ncK�u►os�eo
j lr tA1f pamit In coojwnctba w�Ni a buUdfs=peroit? Ya D Mo O (CLak Appropriate Bos)
P�rpore of B�pdia= Utility Aut�oriratio�Na
E�tla�&rvke A�p� Volts Ove�Yesd O UMd=rd G Na of AtNcrs
Nnr Servke �_ Awp� VoIW Orerfad � Uad=rd O Na ot111ete�s
Nombs�otFeedsn aad Aopaeiry
Loeatba a�d N�t�re ot Proposed Eketriesl Worlc: Cirouits tor ext�e+rior pump coMrdler.Pipe tor=stvice.Upgr�de grounding
compferion of,heJorrowr„g lows inav be w�,nKe by u,e� �of wfns
Na o�Rcces�ed Lumiaairp Na o�C�LL-Susp.(Paddk?��� ha ot Tota�
INa of L��iasir�e Outkts 11a o�ilot T�6s Geoento�s 1►VA
;
'' Na o[f.raieslre� Swlratio�Pool �e p 1�� 0 1�a of Boer�eoe�r U=hdn=
,
Na oi Reecptack O�tleU Na o!Oil Bunen F1RE AI.ARMS Na ot 7.ova
Ka of Swtte6a Ka olGas B�resn ha o[Dctettios aed
I�o.o!Raa�a l�a otAlr Coad. TOu� Na of AkrtisY Devka
' Na of WWe DLposen �1eat P�mp Na otSe�Cool�ioed
Na otD'ahw�shen SpscdArea Uatfs�KW I.ocat O ��'°k��� O Ot6er
NaotDrysrs Iieatia�AppWnte� KW ��� S ��:•
l�a o�Wate� ��y Ya ot N�.ot Data W Wa�:
Na Uydrom�wge Batl�tub� Na otlllotors 2 ToW HP Tekroma�atestbu Wirio�
OTIIER:
Areacb mdraohor dera�!{�de�bsd o.w ny,rnd ey�k�itr,psaor oJwfn�
F.stinnted Vvue of Ekctrical Work: (Wbea eequiad by muaioiPv P��Y•�
Wak w s�arC lospxtion w be roquested ia axadanoe witb MEC Ruk 10.aad upon compktioa
L�iSURA.�iCE COYERAGE:Uakss waived by the mvaer,no permit far the paf'orn�ana of ekctrica[wodc u�ay iasuo unkss t1�e liaascc
prnvides pawf of liability insurarKx Iacludia�•oompkted opentioa'eevera�e a its wbstantial equivakru.TLe undersigned a�tif�d�t wc6
oovera�e�S in for�e.andl�w exhibited proof of same W tlie penmit issuia�ofl'xx.
CNECK ONE:INSURANCE O BOND G OTHER 0 (Spc¢ifjr:)
!arl�/y.�rirda f�Ue pd�u med penol�Ja ojperJary,tAiat tlis lq fonr�lou oR tbls opplJaaflae ls mre aAd ao�t�
FlA.N NMtE: JEFFREY T FOSS
Lkeo�ee: JEFFREY T FOSS Si�sature LtG NO» 36938
N'qpplkabk.swar ruwpr•ae ehe Uce+e�e w+rMber 1rAe,� Bw.Ts6 Na:
Addm�:33 SULWAN RD,W YARMOUTH AAA 02673 AN.TeL Na: 7L-- /„9 B
�Pa M.�L c.14T.s.37-61.secu�ity vwrk requircs Dep�xnt of Public Safeqr"S"Liaasc Tr���'—
OWNER'S iNSURANCE WAIVBR:1 am awat+e that the Lian9e doea not l�avs the liabiliry lnsurance caver�o normally requited by law.But
��natw+e bebw,I hereby waive tbis�oquiremeat I am tLe{check onc) 0 owoer 0 owne�s ageat
OweerlA�e�t
Si=aature TekpbooeNa PERMIT FEE:SSQ00
�/er- �o a.2 ��3��5'K� G��GC�OMGDD
��� ,�/�r��� Ft� � 4 2016
1
HEALTH DEPT.