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� APPLICATION FOR PERMIT TO �ERF�RM ELECTRICAL WORK
Ail wotk to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
OF y4
�21' 9.+t�g (OFFICE USE ONLY)
~ = TOWN F YA MOUTH By !
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W'TTACMElSE `d;c..,`s , - �
�MqO� Fee:
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= 53 PERMIT NO._ �" �I' 31 {,�
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work
�escribed below.
Location(Street&Number) > p�'(iJ/I�
Owner or Tenant ��c-� C s_7 ��� t1 Telephone No.
Owner's Address a+ ��� n /� T 1�
Is this permit in conjunction with a build^ng permit? Q Yes [�No (Check Appropriate Box) • `3�Q
Purpose of Building Utility Authorization No. ��^' � �
Existing Service�Q'�Q Amps� a-ae Volts Overhead� Undgrd� No of Meters /
New Service Amps / Volts Overhead� Undgrd� No. of Meters
Number of Feeders and Ampacicy �-
Location and Nature of Proposed electrical Work: �J( y�.u�� � �i,n��D
(/
Com letion o the ollowin table ma be waived the Ira or o Wire.r
No.of Total
e i t t f il.- I n Transformers KVA
No. of Li hcin Outlecs No.of Hot Tubs Generacors KVA
Above In- No.of Emergency Lighcing
No. of Li hcin Fixtures Swimmin Pool rnd. � rnd. � Bacce Unics
No. of Recepcacle Ouclecs No.of Oil Burners • FIRE ALARMS No.of Zones
No.of Decection and
No. of Swicches No.of Gas Burners Iniciacin Devices
No. of Ran es Tocal
g No.of Air Cond. Tons No. of Alerting Devices
Heac Pump Number Tons KW No.of Self-Concained
No. of Waste Disposers Totais: -- -- -- Detection/Alerting Devices
Municipal
No. oF IJ�ishwashers Space/Area Heating KW Local Q Conneccion � Other
ecunty ystems:
„No.of Dryers Heating Appliances KW No.of Devices or Equipvalenc
No.of Water No.of No.of Daca Wiring:
Heaters KW Si ns Ballasts No.of Devices or Equivalent
No. Hydromassage Bathcubs No.of Motors Total HP Telecommunicacions Wiring:
No.of Devices or E uivalent
' Attach additional detai!if derired,or at required by the In.rpector of Wire.r.
INSURANCE COVERAGE:Unless waived by the owner,no permic for che performance of electrical work may issue unless the licensee provides proof of liabilicy
insurance including"compleced operation"coverage or its subscancial equivalenc.The undersigned certifies thac such coverage is in force, and has exhibited ptoof
of same co the permit issuing o�ce.
CHECKONE: INSURANCE� BOND� OTHER� (Specify:) < <,rw7�vj
(Expiracion Dace)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon complecion.
I cercify, under th ins and penalcies of erju that the information on chis application is true and complece.
FIRM NAME: �� �rr0'���
LIC.NO.
Licensee: Signature LIC.NO.
�(If applicabie, en er"exempc" 'n the license numb line.) � Bus.Tel.No.:�3� �J 3 7
Address: � —� ' w'�c� Alt.Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee dce not have the liability insurance coverage normally required by law.By my signature
below,I hereby waive this requirement. I and che(check one) owner � owner's agent.�
O�vner/Agenc
Si�nature Telephone No.
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