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�t}tt[rtmetct of�ublic $ttftt{� Permit No. • �--���� __
BOARO OF FIRE PREVENTION REGUUlTiONS 527 CMR 12:00 �uPa�cy s r-ee cnecked
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APPLICATION FOR PERMIT TO PERFORM EL'ECTRICAL WORK ;
All work to be performed in accordance with the Massachusetts Electricai Code, 527 CMR 12:00 ''
(PLEASE PRINT IN INK OR TYPE ALL INFORM TION) Date ��Z��� R
City or Town of �• yi�-K-/I�0�1Y� �
---, To the Inspector ot Wires: � i
The undersigned applies for a permit to perform the electrical work described below. -� ;
Location (Street 8 Number) — Z� /V f/9'Cr�}�L.�- L,�g.iU� F��� I
Owne� o�Tenant —. -���'� i�Jr.4✓n"� Tel. No.
• Owne�'s Address � � I
Is this pennit fn co�junction with a building permit: Yes ❑ No
❑ (Check ApPropriate Box) Z
. Purpose of Buiiding _ �- Utility Auttwrization No. D �
EX�St��9 Setv��g�AmpS��/ ZZ4Volts Overhead C`'I� Undgr�d ❑ No. oi Meters � ? I
New Se^n�e Amps__/ Volts Overhead Q Undgmd ❑ No. of Meters �
Number of Feeders a�d Ampaciry /-6 � u '
Location and Nature ot Proposed Electrical Work ���� SL�"�C�(//�?P K-- �
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. C '
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No.ot LigMi�g Outlets No.oi Hpt Tubs No.of Transfwm r� � " '
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nbove ��- r f
Na=ot Liqhdny Fixtures Swimminp Poo1 9� � 9md. ❑ Generators
i No.ot Emerpe ' hting �I
No.ot ReCeptacle Outlets No.o(Oil Bumers Battery Units
No.ot Switch Outlets No_Of Gas Bumers FIRE ALARMS .
Z '
No.of Total No.of Detection and .
��9es No.or Air Co�d. to�s ��itiati�q Dwioss 3 i
No.ot Disposals Na �Heat Total Total
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umps Tons KW No.oi Sounding�evices �
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No.of SeK Co�tained Z
No.of Dishwashars SpacdAroa Heatin9 KW a7etectioNSounding Oevices �
No.aa Dryets Hoatit�Owicas KW � ❑ Connaetion ❑Other =
` No.of No.o( �yb� f
TM�� - No.ot Water Heatera KW C :
Sip�s Ballasts 1fNiring -�
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No. Hydro Massage 7ubs • No.of Motors . Total HP
� OTHER:
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�� �� �� INSURANC�CO'VERAGE:Pwsuent to�he roquirsmeM�s of Massachusetts�eral Laws 1 have a cume�t liability Insurance Policy inelud-
�,, �^0�1D �d Op��tio�s Co�Ws or its wbuantial puivabnt.YES NO O I haw submitted valid proof ot same to the Ot(it:e. �
� , YES NO �q. If frou havs cMclasd YES.Pl�+se indicate the�rpe of c�vera �y Checki�the appropriate
•, INSURANCE CS BON� ❑ OTHER O (Ple�+ise 3PecilY) �O/ri✓1VCA��E ��'1/Z,ld e� �
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(Expiratio�Date) C
Eslimat�d Vatus ot Els�t�ical Wbrk t � ,
��� Inspection Date Requeated: Fiou9h Final n
� SiqMd undsr ths F�naltiss of P�xjury: n
FIRM NAME UC. NO. �/
V �^� �� � Si��aturo
pr UC. N�. CZZ�7�
Addhss /a �� 1I �.IN• f rG����`�1171 �����f Bus.Tel. No. d ��'�tS
Alt,Tel. No.
O'WPIER'S INSURANCE WAIVER;1 am awati that ths Lic;ensee does not have the insura n c e o o v e r a fl e o�I t s s u b s t a n t i a l e q u i v a l e n t a s re- -Lt�
V�i�d bY I�Aas�s Cs�al Laws. and ihat my sipnatu�e on this N -��
������ psrm apPlication waivss this requirement. Owner A ge�t