HomeMy WebLinkAboutElectrical Permit�
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The Commoni.vealth of Massachusetts "`""1�`�;` �''
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Dcparnnrnt of Public So�cty a�,�„�?a FK c,�.�a
BOARD OF FlRE PREVENTiOPt REGULATIONS 527 CMR 1200 3/90 ,�.,�� Olank)
-A�PPLICATION FOR PERMlT TO PERFORM ELECTRlCAL WORK
� � � N1 Work to bc pciiormed!n�ecord�ncc vrith the Massachusetss FJectrical CoEe, 527 CMR 2:00
i (PLEASE PRINT ItI T2IIC OR ' E ALL INFORrIATION) Date
iCity or Town of �_ To the Znspeetor of tiires:
Ihe undersigaed applies for a germit to pexfora tAe electrical �+ork_descriDed Delov.
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Location (Street � Number) � l•�
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� O�.�ner or Ten�nt
'I Owner's Address 1..� =•
j Ia this permit in conjunctio �+ith a building permit_ Yes ❑ No e��PP�AA���x�
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Yurpose of Buildin8 �� Utility Authaziu N0. o
I � Existfng Service J4ops - / Volts Overhead�Undgrd I� �a£�
It7ev S�rvi,ee Amps / Volts Overbead ❑ Undgrd No. of Meu:s��
iNuaber of Feeden and t�mpacity
Location and Hatura of Proposed Electrical Work -� � •+ V
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No. of Lighting Outlets No, of Hot Tubs No. oE Transfoxiners ��y�l
� No. of Lighting Ffxtures Svimming Pool ��°d� grnd. ❑ Generators K1►A
� No. of Receptacle Outlets No. of Oil Burners Battef EUnftSncy Lighting
No. of Switch Outlets No. of Gas Burners FIRE ALA]tMS No. o£ Zones
III No. of Ran es Toul �No. of Detection and
I B No. of Air Cond, tons Initiating Devices
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No. of Disposals No. of peats TTtas To�l No. of Sounding Devices
No. of Dishwashers • Space/Area Heating ICH Ko. of Self Contained
Detection/Sounding Devices
No. ef Dryers Heating Devices � ��al �nicipal Other
❑ Connection�
No 0 0. o
w V 1 a e
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Lo o t
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No. of Water Heatera
KW
B s W
Si ns
allast irin
I�I . No. Nydro Massage Tubs No. of Motors Total HP
OTFIER:
� INSITRANCE�OYERAGE: Pursuant to the requirements of Massachusetts General LaWs
I have a current�t abilit Insurance Policy including Completed OQerations Coverage o��ts substantial
�y equivalent. YES Q(j_ NO[] I Aave :ubmitted valid proof o£ same to this office. YESJ�_ ND ❑
If you have cheo�ea YES, please indicate the type o coverage by checkin tha app pfiaFe box.
�, INSURANCE BOND ❑ OTHER❑ (Flease Specify)� ��„��C-�'�',L����'� v C.t/iJ0
� � iration ate
`Q . Estimated Value of ect cal Work S �~
�� Work to Start Inspection Date Requested: Rough Final
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► Signed under the penalt es o f perjury:
� FIRM NAME � _ . N0.
Licensee ignature IC. Np. ''
Address Bus. Te . No.
Alt. Tel. No. �
� OWNER�S INSURANCE wAIVER: I am aware that ehe Licensee does no have the insurance verage or ts su -
• stantial equivalent as required by Masaachusetts Ceneral Laws, a�nc� that my signature on this permit
application s+aives this requiremeat. O�mer Agent �Please check oae)
I'i Telephone No. PERMIT FEE S
'� � Sigaature of Owner or Agent
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