HomeMy WebLinkAboutElectrical Permit APPLICATION F PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfo med in ccordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
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� � c Fee: $— ��!�
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� (PLEASE PRINT IN INK OR NIATI N ry���� ' � ��'u
) Date: /O p�
� To the Inspector of Wires: By this application the und si�y��i•� ��of �s or her intenti n to p orm the electrical
work described below.
i _�
Location (Street&Number �-�� �
Owner or Tenant �/� ���T,q.,U j V � Telephone No.
� Owner's Address
Is this permit in conjunction with a building permit? � Yes �m (Check Appropriate Box)
Purpose of Building -�C--- Utility Authorization No.
Existing Servicdt�r� Amps_f�� /a tio Volts Overhead� Und
grd.�-____No. of Meters \
New Service Amps / Volts Overhead� Undgrd� No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed electrical Work: �( � >,r �.v C OF' �J�� s' �7.� �Y��-E.f,,—
— v.�.� '` e��S
Com letibn o the ollowin table ma be waived by the Ins ector o Wires
No. of Recessed Fixtures No.of Total
No. of Ceil.-Sus . Paddle Fans Transformers KVA
No. of Li htin Outlets No. of Hot Tubs Generators KVA
No. of Li htin Fixtures Above �7 In- No. of Emergency Lighting
Swimmin Pool rnd. U� md. � Batte Units
No. of Receptacle Oudets No. of Oil Burners FjRE ALARMS
No. of Zones
No. of Switches No. of Gas Burners No. o Detection an
ti Initiating Devices
No. of Ranges No. of Air Cond. Total
Tons No. of Alerting Devices
No. of Waste Disposers Heat Pump. Number Tons KW No. of Self-Contained
� aI Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local � Municipal
Connection � Other
No.of Dryers Heating Appliances KW Secutity Systems:
� No.of Water _ No.of Devices or E ui valent
Heaters No.of No.of Data Wiring:
V KW Signs Ballasts _ No.of Devices or uivalent
� No. Hydromassage Bathtubs No. of Motors Tota1 HP Telecommunications Wiring•
v
No.of Devices or E uivalent
Attach additional detail if desired, or as required by the Inspector o Wires.
INSURANCE COVERAGE: Unless waived by the owner,no pemrit for the performance of electrical work may be issued unless the licensee p ovides
�pzoof of liabihty insutance including "completed operation"coverage or its substanrial equivalent. Tt�e undersigned certifies that such coverage is in
force, and has eJchibited proof of same to the permit issuing office. T
CHECK ONE: INSURANCE �. gp�� OTHER� (Specify:) �
.i#-
stimated Value of Electrical Work:�� (Expuat�on Dace)
(When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
t�FIRMfNAMEr the p 'ns and pen✓ties of perjury, that the information on this application is true and complete.
e '�-� LIC. NO. E�i�
��Licensee: Signat � _ ;
If applicable, enter"exempt"in the license number line.) --- LIC. NO. � ;
' Address• Bus. Tel. No.:
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liabilit}>insurance coverage normally required by law.By my signature
below,I hereby waive this requirement. I am the(check one)owner � owner's agent.Q
Owner/Agent
Signature TeIephone No. `
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