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Fee: $ ��.�°�ln- �� c PERMIT NO. C ��'�0� M''t'!`�'1`:"-" "~ '_ ": � (PLEA5E PRINT IN INK OR TYPE A ) Date: � � ' ' � i' i�' ^ ' To the Inspector of Wires: By this application the undersigned gives notice of his or her intention a erform the electric �i iK work described below. � `�j`� �,�� . 2��2 + � ;� _ Location (Street& Number •'23 � � L/�'� L�_�t Owner ar Tenant l'��'�� I lf:�M Teleph $ � � Owner's Address �� • Is this permit in conjunction with a building permit? � Yes �No (Check Appropriate Box) Purpose of Building .�IfJ�LC.�lG UtilityAuthorization Na Existing Service Amps / Volts Overhead� Undgrd� No. of Meters New Service Amps / Volts Overhead� Undgrd� No. of Meters Number of Feeders and Ampacity �Location and Nature of Proposed electrical Work:�� :�� r��p �W S �'+�� '�� w.c�c.sL a�- k��f' ,�r� � P�y c��, l� �— �� Co�n�letion o the oUowin table ma be waived b the Ins ector o �res No. of Total No. of Recessed Fixtures No. of Ceil.-Sus . Paddle Fans Transformers KVA ► No. of Li htin Outlets No, of Hot Tubs Generators KVA Above In- No. of Emergency Lighting No. of Li htin Fixtures Swimmina Pool Qrnd. � rnd. � Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. o Detechon and No. of Switches No. of Gas Burners Initiating Devices Total No. of Ranges No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self-Contained 'J No. of Waste Disposers Totals: -- - - -- Detection/Alertin Devices l� Municipal � No. of Dishwashers Space/Area Heating KW Local � Connecuon � Other � Secutity Systems: � No. of Dryers Heating Appliances KW No.of Devices or Equipvalent No. of Water No. of No. of Data WirinQ: Heaters ICW Si ns Ballasts No.of�evices or Equivalent � No. H dromassa e Bathtubs No. of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent �7 Attach additional detail if desired, or as required by the Inspector of Wires. 41NSURAtdCE 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 e permit issuing office. '' �CHECK ONE: INSURANCE � BOND� OTHER� (Specify:) / � � (Ex ration Date) Estimated Value of Elec rical Work: (When required by municipal policy.) `� Work to Start: 6 Inspections to be requested in accordance with MEC Rule 10, and upon completion. � I certify, under t mJs and p,e��'a,lt,�ies of�p krjury, that the i7formation on this application is true and complete,/� FIRM NAME: � ` �7'T�� `7 LIC. NO. /�+�6�3� Licensee: �/,I�� /"�' �T'/��►�E'� Signature . LIC. NO. (If applica�e, enter "exempt" in the license number 1'ne.) Bus. Tel. No.:�bY �,./�� $� Address /'.�� C �57��''��Y«� B.�i�?� Alt. Tel. 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 [ am the (check one)owner � owner's agent.� � Owner/Agent Signature Telephone No. f Rev.04/00�