HomeMy WebLinkAboutElectrical Permit � as
APPLICATION FOR PERMIT T4 PERFORM ELECTRICAL WORK
All work to be performed in ac'cordance wich che Massachusetts Electrical Cade, (MEC)> 527 CMR 12.00
�s � Y''9� � � n � i? ['� � j` �oF�icE us� oN� � � �� � 0 M C D
��� `.� �
,�„ � TOW `�t7��,YI� !1 By o5
�� �r���. } Fee: $
�
� �S � �AL7-H �LF'C'.
y PERMiT NO. "� �
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � ` l� ' �
To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical
work described below.
Location (Street&Nurnber) O � ��-O Qv D (rJ �O v��-dA�D �,,)t� 7 X�(��f'i'U f lf
Owner or Tenant (,,� j�„(�--�� �1���� �`'t OC�' �. � Telephone Na
Owner's Address ���� �
Is this permit in conjunction with a building permit? � Yes (�No (Check Appropriate Box)
Purpase of Building ��(.��(r Utility Authorization No. h{ f} ,
�Existing Service ' � Amps�!D / "l� a�t�'Volts Overhead'� Undgrd� No. of Meters j
New Service Amps / Volts Overhead� Undgrd� No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed electrical Work: . t �4 7,� � �� `C[� �J r�l Q rt /���,..1`'�
� Co letion o the allowin table ma be waived b the Ins ector o Wir�
No.of otal
:
N . o Fi t re . f ei.- a s Transformers KVA
� No. of Li htin 4 No. of Hot T1ibs Generators KVA
Above n- No.o mergency Lightm
'" No. of Li htin Fixtures Swimmin Pool d. � rnd. � Batte Units
e�y No. af Receptacle Outlets f Oil Burners FIRE MS No. of Zones
� No.of Switches Na.of Gas ers •o tection an
Initiatin Devices
• No. of Ranges No. of Air Cond. �t S No. of Alerting Devices
eat mp um on No. of Seif-Contained
� No. of Waste Disposers Totals: -- -'" � Detecrion/Alertin Devices
Municipal
�j No. of Dishwashers Spac ea Heating KW al � Connection � Other
Secutit tems:
No.of Dryers Heating Appliances KW No.of ' s or ui vatent
No.of Water No.of No. of Data Wiring:
Heaters K Si ns Ballasts No.of Devices or nt
�j I�to. H dromass athiubs No. of Motors Total HP Telecommunications Wiring: '
Y No.of Devices or uivalent
�\ Attach addilional detail if desired, or as required by the Inspector of Wire:
NSURANCE 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 the permit issuing office.
CHECK ONE: INSURANCE �. ,BOI�TD� OTHER� (Specify:)
Estimated Value of Electrical Work: ��t7 U (Expiration Date)
(Wt�en required by municipal policy.) ,
Work to Start: -� !�i -�C��Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: i ' � p t LIC. NO. L' 30� ��'
� icensee: �", � , �,�,�x{(J- Signature LIC. NO. L�-LSl�`D '
(If applicable nter"exem t" in the license number line.) Bus.Tel. No.:
J Address• �c Cc�- t � �/ Ait. Tel. No.: SO�--�t0o •- �3 3 �
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance coverage normally required by law.By my signatw !
below, I hereby waive this requirement. I am the(check one)owner � owner's agent.[� i
Owner/Agent �
i
Cionatnra TatAnh�,na Nn �