HomeMy WebLinkAboutBLDE-97-398w
WtUc
The Common -
h of Masscrchuset rermtr .o.
e�r','m P"' —�-- .. v ��. .i!. Occupa nc }� 6 Fee Checked_
BOARD OF FIRE PREVENTION REGULATIONS S27 �, m._ T"17 3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordance with the Macsachusetu Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK ORTYPE {ALL INFORMATION) Date
C
City or Town of )6102'x- YM&AW Ol To the r § Vires@
/ The undersigned applies for a permit to perform the electrical vork des 1bjd below.
i
J Location (Street & Number)
Owner or Tenant Alf. W
Owner's Address (uf►/+��� ) t i
Is this permit in conjunction with a building permit: Yes ❑ No ® (Check Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service /f�0 Amps 191e) / �I-V6 Volts Overhead ® Undgrd ❑ No. of Meters_L_
New Service Amps / Volts Overhead ❑ 'I Undgrd ❑ No. of Meters
Number of Feeders and Ampacity 466001
/(
Location and Nature of Proposed Electrical Work sAy-'A `,rr6001
No.
of Lighting Outlets
-
No. of Hot Tubs
lot:a>.
No. of Transformers KVA
No.
No.
of LightingFixtures
Swimming Pool Above In-
g grnd. ❑ grndNo.
KVA
. Emerge:..
of Rece tacle Outlets
p
No. of Oil Burners
tter Units
er
No.
of Switch Outlets
No. of Gas Burners
Total.
RE ALARMS,No. of Zones
of Detection and
No.
of Ranges
No. of Air Cond. tonsnitiating
Heat Total Total
No. of Pumps Tons KW
Devices
No. of Sounding Devices
No. of Self Contained
No. of Disposals
No.
of Dishwashers !
Space/Area Heating
Detection/Sounding Devices
Local ElMunicipal ❑ Other
No.
of Dryers
Heating Devices
Connection
No, of No. of
w Voltage
No.
of Water Heaters KW
Signs Ballasts
Wiring
No.
Hydro Massage Tubs
No. of Motors Total HP
OTHER: -ter"-
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES p NO ® I have submitted valid proof of same to this office. YES ❑ N0.®
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify)
(Expiration Date
Estimated Value of Flectrical Work $
Work to Start Inspection Date Requested: Rough_
Signed under the penalties of perjury:
FIRM NAME /411,1 r� - CQ A7 ;?25
Final
LIC. NO.
T _
Licensee Signatures �/����"- "/ ���' LIC. NO. Z
Bus. Tel. No.
Address
Alt. Tel. No -3 %L7�i�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massach etts General Laws, and that my signature on this permit
appl ation aives t is a irement: Agent\ (Please check one
Telephono o.,_3
/y—PERMIT FEE $
nature of Owner r Ant
ge