HomeMy WebLinkAboutElectrical Permit � COm Official Use Only
� monwealth of
� � Massachusetts PermitNo. BLDE-16-002493
'"� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ��?;� i';, i ���) �
ev.1/07 t
APPLICATION FOR PERMIT TO PERFORM ELECTRICA VV���2Di5
All work to be performed in accordance with the Massachusetts Electrical Code (MEC),527 CMR 12.0(� _
(PLEASE PR/NT IN INK OR TYPEALL/NFORMATlON) D�f,B:1 O/28/2015 � �' �' � `
C'lty ol'TOwri Of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives no ice o ts or er m en ion o pe orm e e ec c work described below.
Location(Street&Number) 34 SIOUX RD
Owner or Tenant MAGOWN JAYNE TRS Telep6one No.
Owner's Address THE VP WEST YARMOUTH REALN TRUST, 132 SUMMER ST, NORWELL,MA 02061 '
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Boa)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps Volts Overhead ❑ Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: SeptiC pump&alaml
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Faus No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above � In- � No.of Emergency Lighting
rnd. rnd. Ba Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones '
No.of Switches No.of Gas Burners No.of Detection and
Imtiatin D �
No.of Ranges No.of Air Cond. Tons� No.of Alerting Devices '
No.of Waste Disposers Heat Pump Number T n KW No.of Self-Contained
T al : D e tion/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local D Municipal p Ot6er:
Connection
No.of Dryers Heating Appliances KW Securi Systeros:*
N f e i nt
No.of Water �, No.of No.of Data Wiring:
H rs Si ns Ball N f Devi s or E ' 1 '
No.Hydromassage Bathtubs No.of Motors Total HP Tetecommunications Wiring: �
ce r ' a eut �
OTHER: ;
i
Attach additional detail if desired,or as required by the Inspector of Wires. ;
Estimated Value of Electrical Work: (When required by municipal policy.) �
Work to start: Inspecrion to be requested in accordance with MEC Rule 10,and upon completion. i
INSURANCE COVERAGE:Untess waived by the owner,no permit for the performance of electrical work may issue unless the licensee
provides proof of liability insurance including"completed operation"coverage or its substanrial equivalent.The undersigned certifies that such �
coverage is in force,and has exhibited proof of same to the permit issuing office. '
CHECK ONE:INSURANCE 0 BOND ❑ OTI-IER ❑ (Specify:) !
I certify,under the pains and penakies of perjury,that the information on this application is true and complete
FIRM NAME: SIMONIS ELECTRIC INC
Licensee: MICHAEL F SIMONIS Signature LIC.NO.: 16862 �
(Ifapp/icable,enter"exempt"in the license number line.) Bus.Tei.No.•
Address: PO BOX 1488,EAST DENNIS MA 02641 Att.Tel.No.:.
*Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License:
OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But
signature below,I hereby waive this requirement.I am the(check one) ❑ owner ❑ owner's agent. !
Owner/Agent �;
Signature Tetephone No. = PERMIT FEE:$50.00 '
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