HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMtT�T� PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC),527 CMR 12.00
�,.� � r49 _ (OFFICE USE ONI.Y) (Rev.9/05)
� � �;F,�0��1 F RII�UTH By
_ , Y�i
��"Eme , Fee: $_ 'C�
�
'i: ._ ���� � . ';' PERMIT NO. C:. "D/ ""' ��(o �
�. �� 5-�
� �L. „�. , .
(PLEASE PRINT IN I �_�'�-'�,,��F.�ATION) Date: f ��
To the Inspector of Wires: By this application the undersigned gives notice of his or her intenti n to p rform the electrical
work described below.
Location (Street&Number � � '
Owner or Tenant Telephone Na '
Owner's Address �
Is this permit in conjunction with a building pernut? I� Yes �No (Check Apgropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps ( 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:�J�� ��..�7 ,V C� `
� Com tetinn o'the allowin table ma be waived b the Ins ector o Wires
� No.of Total �
No.of Recessed Luminaires No. of Ceil.-Sus . Paddle Fan Transformers KVA
`",'!�. No.of Luminaire Outlets No. of Hot Tubs Generators KVA . '
� A ove n- No.o Emergency Lighting
N o.o f L u m i n a i r e s S w i m m i n P o ol rnd. � rnd. � B a tt e U n i t s
`�' No. of Receptacle Outlets No. of Oil Bumers FIRE ALARMS I�To. of Zones
o.o tecUon an
No. of Switches No. of Gas Burners Initiatin Devices
Total
No. of Ranges No. of Air Cond. Tons No. of Alerting Devices
eat Pump um r ons No. of Self-Contained _
- No.of Waste Disposers Totais: -- -- -- Detec6on/Alertin Devices
No.of Dishwashers S ace/Area Heatin KW Local � Municipal � Other
P g Connection
�6 No.of D ers Hearin A liances KW Security Systems:*
rY g PP No.of Devices or Equivalent
No.of Water No. of No.of Data Wirin�:
Heaters KW Si ns Ballasts No.of l�evices or Equivalent
No. H dromassa e Bathtubs No.of Motors Total HP Telecommunications Wiring: 4
Y $ No.of Devices or uivalent :
'� Attach additional detai!if desired, or ns required by the Inspector of Wires.
[NSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may be issued unless the licensee provides '
roof of liability insurance inciuding"completed operation" coverage or its substantiai equivalent.The undersigned certifies that such co erage is in �
' force, and has exhibited proof of same to the permit issuing office. ;
CHECK ONE: INSURANCE {� BOND� OTHERQ (Specify:) �v ,
(Expirati n Date)
Estimated Value of Electrical Woik: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Ru(e 10, and upon completion.
I certify, under ' s and ! ' � o , that e i f p n this a p ication is true and complete. ,�-�
FIRM NAME: � NO. �c���7O��
Licensee: Signature LIC. NO. i
(If applicab , en r"e;cempt" in the 1�s u r li e us.Tel. No.: ,
Address• - �o Alt. Tel. No.: i
*Security System Contractor License required for this work;if applicable,enter he license number here:
OWNER'S INSUT2ANCE WAIVER: I am aware that the Licensee dces not have the liability insurance coverage normally required by (aw. By my si�nsture `
be]ow, I hereby waive this requirement. [am the(check onel owner Q owner's agent.Q i
OwnerlAgent