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APPLICATION FOR RERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
OCT i i 001
(OFFIC -.WASE-•�
By
L G�>3
Fee: $ 0 C i
iLD
PERMIT NO. t
(PLEASE PRINT IN INK 01�- �N) Date: %7 • /0 A 6
To the Inspector of Wires: By this application the undersigned gives notice of his or her intion to perform the electrical
work described below
Location (Street & Number)Q3 a� mauve
No. of Ceil.-Susp. Paddle Fans
No. of Total
Transformers KVA
ghting Outlets
No. of Li-
i, ` / .
Owner or Tenant V__ Ia' O� �
�` C'i
l� G
Telephone No.
Owner's Address 'Say -n `e —
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
Is this permit in conjunction with a building permit?
17)
Yes No
(Check Appropriate Box)
Purpose of Building
Total
No. of Air Cond. Tons
Utility Authorization No.
Existing Service Amps /
Volts
OverheadC]
Undgrd [7) No. of Meters
New Service Amps /
Volts
OverheadO
Undgrd 71 No. of Meters
Number of Feeders and Ampacity ��m go(
Location and Nature of Proposed electrical Work:
Com letion of the follo wing table maybe waived by the Insector o Wires
60
No. of Recessed Fixtures
No. of Ceil.-Susp. Paddle Fans
No. of Total
Transformers KVA
ghting Outlets
No. of Li-
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
AboveIn-
Swimming Pool grnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. Detection and
Innitiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
— —
Tons
—'—
KW
— —
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
Local �y Connection Other
No. of Dryers
Heating Appliances KW
Sec No of Devices or Equipvalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring.
No. of Devices or Equivalent
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 operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in
force, and has exhibited proof of same to permit issuing office.
!CHECK ONE: INSURANCE BONDO OTHER (Specify:)
/ (Expiration Date)
Estimated Value of Electrical Work:— aQ • — (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under th ams and penalti f per Iury, that t formation on this application is true and complete.
'FIRM NA % G�S'�t� GF % LIC. NO. `S !o
Licensee: Signature Z _LIC. NO. �� z
(If applicable, enter `exempt" in the license number line.) 7 -
Bus. Tel. No.:
"Address: Alt. Tei. No.: "
OWNER'S INSURANCE WAIVER: I am aware 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 171 owner's agent. 71
Owner/Agent
Signature Telephone No.
[Rev. 04/001