HomeMy WebLinkAboutElectrical Permit APPLICATIDN��OR �ERMIT`TO�PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC),527 CMR 12.00
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� ` � � � � PERMIT NO. � ���'��
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(PI,EASE P�ZINT IN INK OR ` ' � Date: /�2,�D�.
To the Inspector of Wires: By this application.the,und�rsigned gives notice of his or her intention to perform the electrical
work described below.
Location(Street&Numberl__ � ��t r"t n a� 2 �
Owner or Tenant�'�, e F us; S j- � %! � .SYS�".��' Telephone No. �7 y�$3(e� f.773
Owner's Address �� �-� ����� 3 �'Yt +9 .
Is this permit in conjunction with a building p�rmit? �Yes [�To (Check Appropriate
Purpose of Building R���n S,v C� Utility Authorization No.
Existing Service Amps / Volts Overhead� Undgrd� No. of Meters
j New Service Amps / Valts Overhead� Undgrd� No. of Meters
�' Number of Feeders and Ampacity
Location and Nature of Proposed electrical Work: ov r�� s'��I C L I /�� /�c�� 1� SY$/�i'�(
' Com letion o the ollowin table be waived b the Ins ector o Wires
'
No.of Total
No. of Recessed Fixtures No. of Ceil.-Sus . P dle Fans Transformers KVA
� No. of Li htin Outlets No. of Hot Tubs Generators KVA
ove In- No.of Emergency Lighting
No. of Li htin Fixtures Swimmin Pool d. � md. � Batte Units �
No. of Receptacle Outlets No. of Oil Burners FIRE AI.ARMS No. of Zones
I' '�9 No. of Switches No. of Gas Burners o• o Detect�on an
Initiating Devices
Total
No. of Ranges No. of Air Cond. Tons No. of Alerting Devices
�" eat mp um er ons No. of Self-Contained
No. of Waste Disposers Totals: -- -- -- Detection/Alerting Devices
� Municipal
� No. of Dishwashers ' SpacelArea Heating KW Local � Connection � Other
Secutity Systems:
No.of Dryers Heating Appliances KW No.of Devices or ui valent
No. of Water No.of No.of Data Wiring:
Heaters KW Si ns Ballasts No.of Devices or Equivalent
No. H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring:
y g No.of Devices or uivalent
� Attach additional detail if desired, or as required by the Inspector of Wires.
^� INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may be issued unless the licensee provides
proof of liability insurance including"completed operaflon"coverage or its substantial equivalent.The undersigned certifies that such coverage is in
rce,and has e�ibited proof of same to the pernut issuing office.
` CHECK ONE: INSURANCE �' BOND� OTHER� (Specify:)u/�/d KPart S c�.+�� 31?S�D 7
� � � � (Expiration Date)
stimated Value of Electrical Work: � •1,'�6� (When required by municipal policy.)
� Work to Start:�Je��Q L Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pams and penalties of perjury,that the informadon on this application is true and complete.
RM NAME: �V,�i',G S � �_F G% �.rs C LIC. NO. � 7 S��
Licensee:,rj�f�,SB,v r . �o ,tJ �. Signature_��v� " � LIC. NO. � / '7/`7 I
(If applicable, enter"exempt" in the license number line.) Bu .Tel. No.: S'oS�� 77,i— �T 3 0 �
Address: Alt. Tel. No.�e g}� y�� — e *,Zy�_
OWNER'S INSURANCE WAIVER:I am awaze that the Licensee does not have the liability insurance coverage normally required by law.By my signature
below,I hereby waive this requirement.I am the(check one)owner Q owner's agent.�
Owner/Agent
Signature Telephone No.
[Rev.04/00]