HomeMy WebLinkAboutElectrical Permit � �� 011ice Use On1y
v L�1C C�'1TI11I11AIT11�'['c�Ifjl iYt �cZ.'r��.�--�-�-- Perm�� t�o. ' _ " � I
� + '� . �
�. '' � "� t1C�lart�ncnt nf �'}ublic '��IU �- i Occupa�cy& Fee Checked �""
� � �� � (Yeave blank) � �
SOARD OF�lAE PREVENTI�N REGULATIO �����' OOZ � �� �
���� �pPL1��AT10N ���F�C)�R P�ER11��T �T��� PERF�RI�1 ���.��CTRiCAL W�RK
� '^ All work to be performed in accordance w;ih�t�e � 1�Code, 527 CMR 12:00�
______�_. _ . .?�t.��G 2--
� p�., (PLEASE PRINT IN 1hK OR TYPE ALL fN�OF�MATION) Date
,� City or Tawn oi� ��-lLta3'-F'�t h��,l�s�'. To the inspector of Wires:
a The udersigned appPies for a pe�mii to perlorm the eiectrical work described below.
� Location {Street & Numberj ��� �(u��-� ��� C� /�f`��J�� ���
Owner or Tenant �C R-�� �E
� ¢ � Owner's Address ��Cf3� Tel. No, ��'�'������$�
'� I I is this permit in conjunc2ion with a building permit: ` Yes ❑ No ,� (CheCk Appropfiate Box)
� � ` -
� n �f � �� _� __
; o •^^�il ^! ^11i�c?s^ �C ..r�-�e Ui�iitv Aumofi�a�ion No.
_ _.. _ ._ . ..,�.�.._:,�.
� �. . �_..� .
� (' I Existing Service Amps __/ Volts Overhead ❑ Undg�nd ❑ No. ot Meters
� New Service � Amps _.J Voits Ovefhead ❑ Undgrnd ❑ � No. of Meters
� W
r-� W
c:. ;:. Number of Feeders and Ampacity
l.ocation and Naiure of Proposed Electrical Work -��5'E�t�l ��f�j�- PU v� P - `'�'� �-e-
w w
� � �v c��',].
� � No. of �ighting Outiets No, of Hot Tubs No. of Transformers TO�A
No. of Lighting FixWtes Swimming Poo! �gQ 9
grnd. r�d. ❑ Generators �A
Na. of Emergency Lighting
� No. 04 Receptac}e Outleis No. oi Oil Burners 8atiery Unils
No. 01 Swiiches No. ot Gas Bwnets FiRE ALARMS No. ol Zonas
W W
H � No. o( Ranges No. ot Air Cond. TO� No.o(Detection and
� �, tons Irutiating DeviceS
�
� `^�' No. of Disposals No.ol Hsat Total Total
� � Pumps Toru KW No. ot Sounding Devices
No. o(Selt Contained
�No. of Oishwashers Space/Area Heating KW DeteciioNSounding Devices
�i
.Ww, No. oi Oryers Heaiing Devices �(W �$1 Mu�icipai O Other
H ❑ Connection
� t�a. o! No. ol i..ow Voltage `
����"„ .,_,�__.. ��;;::n�_ I
��Jv. u7 :':o,e� ntya.ur.�', i�.: ..�i:�.ry:s . ...�.�.»... .
x '� �
y� No. Hydro Massage Tubs No. of Motors Total HP Security System
� OTHER:
_ �NSURANCE COVERAGE: Pursuant io the requiremenss of•Massachusetts general Lavvs
i have a current l.iabikity Insurance Policy including Comp ted Operations Coverage or its substantia! equivalent. YES � NO Q �
='' have submi[ted valid proof o1 same to the OHice. YES �NO O II you have checkad YES, please indicate the type ot coverage by
�
� checking the app priate trox.
� lNSURANCE �BpNO O OTHEA D (Ptease Specify) ' (Expiration Oaie)
:-�
7 CN.ECK APPROPRIATE BOX• I have Worker's Compensation Insurance � I have no Faeployees ❑
=-�
Esumated Value o( Electrica! Work S J d��
� work to Start Inspecsian Date Requested: Rough ��/ // �� Fina! �"" � ��, ����
Signed under the Penalties ol perjury: �j,� /
�� FIRM NAME . ��Q�G3��1� �+f/�a �ar �7�'�� �LG�T�f;�. • I.IC. NO.
� ucensee m�'T7�/fE� � fSSt+e6 IvS%�% g�9nawre �� `�d ,r� uC. NO. J�k���
x .iddress 7/ L�37/�2C1 Pc� !�. W � �jrit�/CfJT��P> {'�"1�+ �Z�fo�' 8A 1. Tel. No. �nD��+ '��J�l�
:.J
�7 OWNER'S WSURANCE WAIVER: 1 am aware that 1he �iCensee dOes nol have Iha insurance coverage or its substanual equ�va�ent as re•
Gu�red by Massachusetts Gene�al Laws, and that my signature on this permit appticalion waives th�s requirement. Owner A92n�
(Please check one)
Telephone No. PERMIT FEE 3
(S�g�awre of Owner or Aqern)