HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMiT TO PERFORM ELECTRICAL WORK '
All work co be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00 '
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�,'2' � (OFFICE USE ONLY) (Rev.9/05)
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M��ACNEESE �� .
'-.wtte�° Fee:
AP� � � s .:�..' PERMIT NO. C. ��� Z fJ
(PLEASE PRIIVT IN INK O�P��Az�INFO����[7701C/)" Date:
To the Inspector of Wires: By t�is application the undersigned gives notice of his or her intention o perf rm the electrical :
work described below. ��� ��1�/� ' ���+ C�� ���G�
Location (Street&Nu er 1,.� X�
. Owner or Tenant � � ��' '�� Telephone Na ;
Owner's Address
' Is this pernut in conjunc 'on with a building pernut? � Yes o (Check ropriate Box)
Purpose of Buildin ,�� �ility orization No.
Existing Service,1� Amp Volts Overhead Undgrd� No. of Meters
New Service Amps_ / Volts Overhead� Undgrd� No. of Meters �
Number of Feeders and Ampacity
Location and Nature of Proposed electrical Work: ��Z�'" L=G ��``��'��
Com letion o the oltowin table ma be waived b the Ins ector o Wires
No. of Total '
No.of Recessed Luminaires No. of il.-Sus . Paddle Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
A ove In- No. of Emergency Lighting
No.of Luminaires Swimmin Pool rnd. � rnd. � Batte Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones
o.o etect�on an
No. of Switches No. of Gas Burners Initiating Devices
Total
No. of Ranges No. of Air Cond. Tons No. of Alerting Devices
eat Pump Number Tons W No. of Self-Contained
No. of Waste Disposers Totals: �— �— -- Detection/Alerting Devices
� No. of Dishwashers S ace/Area Heatin KW Local � Municipal � Other
P S Connection
No. of D ers Heatin A liances KW Securiry Syscems:*
� rY g PP No.of Devices or Equivalent
�:" No.of Water No.of No.of Data Wiring:
� Heaters KW Signs Ballasts No.of Devices or uivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs No.of Motors Tota1 HP No.of Devices or E uivalenc
Attach additional detail if desired, or as required by the Inspector of Wires.
� INSURANCE COVERAGE: Unless waived by owner,no pernut for the performance of electrical work may be issued uniess the licensee provides
� proof of liability insurance including"compl operation"coverage or its substantial equivale .The undersigned certifies that such coverag is in
force,and has exhibited proof of same to e permit issuing office. ���
�'`CHECK ONE: INSURANCE BO D OTHER� (Specify:) /�'�' ���
(Expiration )
�Estimated Value E tric Work: � (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify,under e f e lties o ' , at the informarion on this applic tion is true and complete. ` f�y
FIRM NAME: `IG� � �` ` LIC. NO. �/� �`� /
Licensee: Signature "'" LIC. NO.
-; ; (If applicabl , e f�` xe 'ji�y„th ' n r e.) � ` ���,,� Bus.Tel. No•��--' "`—
� Address• l �f� Alt. Tel. No.: ,y
�, � —
` *Security System Contractor License required for this work;if applicable, ter the license number here:
OWNER'S INSURANCE WAIVER:I am aware that the Licensee dces not have the liability insurance coverage normaliy required by law.By my signat�re
below,I hereby waive this requirement. I am the(check one)owner � owner's agent.Q
jOwner/Agent ` ,
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