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APPLICATION FOR PER,MIT TO PERFORM ELECTRICAL WORK
All work ro be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
OF y,4
03? 9;g (OFFICE USE ONLY)
`' - = TOWN OF YARMOUTH By
. M��ACMEESE ��' /T7� ;
"�wutm�* Fee: $ ��
' PERMIT NO. v�� — 1- Z .
(PLF�9SE PRINT IN INK OR 7'YPE ALL INFORMATION) Date: � "' � O
To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical '
wark described below. '
Location(Street&Number 3 ,
Owner or Tenant � Tel on
Owner's Address � � �
Is this permit in conjunction with a buildin�-pernut? � Yes �No (Check Appropriat Box)AU� , 2 '
Purpose of Building rn (,� Utilit Authorization No. � B�j�-D!� �
�r-��JL�—��� Y f i5 p
Existing Service Amps / Volts Overhead� Undgrd� No. o
New Service Amps / Volts Overhead� Undgrd� No. of Meters
Number of Feeders and Ampacity '
� Location and Nature of Proposed electrical Work: 1�t� !` ������L G ��,/�r[/� � ����
-�� D
� Com letion o the ollowin table ma be waived by the Ins ector o Wires
No.of Total
� No. of Recessed Fixtures No. of Ceil.-Sus . Paddle Fans Transformers KVA
No. of Li htin Outlets No. of Hot Tubs Generators KVA
Above In- No, of Emergency Lighting
No. of Li htin Fixtures Swimmin Pool grnd. � md. � Batte Units
i
� No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones �
� No. o Detection and �
No. of Switches No. of Gas Burners Initiating Devices
Total i
No. of Ranges No. of Air Cond. Tons No. of Alerting Devices
No. of Waste Disposers Heat omp• Num er Tons KW_ No. of Self-Contained '
aI Detection/Alerting Devices
Municipal
No. of Dishwashers SpacelArea Heating KW Local � Connection � Other ;
No. of Dryers Heating Appliances KW Secutity Systems: '
� No.of Devices or E ui valent
No.of Water No. of No. of Data Wiring:
Heaters KW Signs Ballasts No.of ISevices or uivalent
� Telecommunications Wiring• ;,
No. Hydromassage Bathtubs No. of Motors Total HP No.of Devices or E uivalent
I
Attach additional detail if desired, or as required by the Inspector of Wires. '
INSURANCE COVERAGE: Unless waived by the owner,no pernut 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 certi�es that such coverage is in
force, and has exhibited proof of same to the pernut issuing office. �
� CHECK ONE: INSURANCE �` BOND� OTHER� (Specify:) ,�
� (Expiration Date) ;
Estimated Value of Electrical k: (When required by municipal policy.)
Work to Start: � — Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, nnder the pains and penalties of perjury, that the information on this application is true and complete. '
FIRM NAME: LIC. NO. '
Licensee: ` Signature LIC. NO. ,�,,
(If applicable, e r"exem t" i the ense nu line.) Bus. Tel. No.•��r �
Address� � .S Alt. Tel. No.:
OWNER'S INSURANCE WAI R:I am aware that the Licensee does not have the liability insurance coverage normally required by law.By my signature '
below,I hereby waive this requirement.I am the(check one)owner � owner's agent.�
Owner/Agent ,
Signature Telephone No. ,