HomeMy WebLinkAboutElectrical Permit , � �omrnon.weal�o��ae�ac�e�• Official Use Only
c� c7 Permit No. l_...� 'V'" / �8
• - eLJePartment o`..tire�ervices ��
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATI�P�� �. [Rev. 1/07] (�eaveblank)
APPLICATION FOR PERMIT TO PE���F�M ELECTRICAL WORK
All work to be performed in accordance with the Massachu�p;rs c�eCtncal Code(MEC),527 CMR 12.00
� - �-�LEASE PRINT IN INK OR TY E ALL INFORMATION) ' Date: �--� �
� �o � City or Town of: �4��ic.v+'tN To the Inspector of Wires:
� By this application the undersigned gives notice of his or her intention to perform the electrical work described bel
` � �-o L,Acation(Street&Number) LcS '�}tl?T K•�-� �--�.��� �� .-
"� E�yvner or Tenant � 'V�,E�1�-� Telephone No. -; �
, . � Z'�v� �f4 � ._
()�ovner's Address c�h-M� ' �j
� v
�_ Is th�permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box)
— _ ,;
•-_ � Pu�pse of Building � e.vp,�(,�,�,�.[[. Utility Authorization No.
Existing Service (� � Amps 1�a /a�c'�Volts Overhead�., Undgrd❑ No.of Meters i
New Service Amps / Volts Overhead:�`, _�, Undgrd ❑ No.of Meters
Number of Feeders and Ampacity Y ��, i
Location and Nature of Proposed Electrical Work: ��.I.,�j--(�-�;,'�'�:e��-(��U �'C 1' �i�RL i
- " �� ,�-�l� �..�re-� ��11 l 1✓t
Com letion o the ollowino table mav be waived by the Ins ector of Wires.
No.of ssed Luminaires No.of Ceil:Susp.(Paddle)Fans No.o Total
„ Transformers
No.of Luminaire ets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above � In- � o. ergency ig mg
rnd. rnd. ter Units
No.of Receptacle Outlets o. il Burners FIRE ALARMS No.of Zones
\ , No.of Switches No.of Gas Bu s � No.of etection and
�. ��ar:.
Initiatin Devices
� No.of Ranges No.of Air . : � No.of Alerting Devices
�No.of Waste Disposers eat p Number.. ...,.on ��``` ' : No.of Self- ontained
� otals: , Detection/Alertin Devices
� No.of Dishwashers Space/Area Heating KW Lo unicipal � �er
Connection
c� No.of Dryers , Heating Appliances 'I{W� Security ms:*
� No.of ev� or E uivalent
� �v No.of Water KW No.of No.of Data Wiring:
Heat Si ns Ballasts No.of Devices or E uivalent
No. romassage Ba�htubs No.of Motors Total HP Telecommunications Wiring.
No.of Devices or E uivalent
THER:
Attach additional cletail if desired,or as required by the Inspector of Wires.
� Estimated Vahie of Electrical Work: (When required by municipal policy.)
� Work to Start: Inspections to be requested in accorda.nce with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no perm�`_..: `�,e performance of electrical work may issue unless
the licensee provides proof of liability insurance including"complete � ���"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibite��� � �;�;' ,,^•ne to tlie permit issuing office.
� CHECKONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Sp::�tf , ,
�l certify,under thepains and penalties ofperjury,that the informa;. �? • ,�.�,plii�ution is true and complete.
� FIRM NAME: I-..��.tC� � ,,ptZVl1G - LIC.NO.: L f��{C�
� Licensee: ; �,,.��� Signature �� LIC.NO.• Ct��{g�
(If applicable,ente "exempt"in the license number line.) � � Bus.Tel.No..' 33
� Address: o�, �X �'�.[�t7 � ., Col/�1 ��� _���6�( Alt.Tel.No.:
� *Per M.G.L.c. 147,s.57-61,security work requires Department of Puotic ;afety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee c���es not have the liability insurance coverage nonnally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)��owner �owner's a ent.
Owner/Agent
Signature Telephone Na�_ PERMIT FEE: $