HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMIT TO PERFO�M ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
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� ' = T F YA� H � By �
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,r, Y 2 I 2001 Fee: $ ' ��� 9�g' S �-/�d/
� BY PERMIT NO. _ f'�/ 7��
(PLEASE PRINT IN INK OR TYPE ALL INFORMA N) Date: pr
To the Inspector of Wires: $y this application the undersigned gives notice of his or her intention to perform the electrical work
described below .
Location(Street&Number) _ �L9 ��sle,�l«� _�� '
"�T'
Qwner or Te�nant �_,� ��'f,� Telephone No. �
Ownet's Addr�ss
�� Is this permit in conjunction wich a building permit? ❑Yes �No (Check Appropriate Box)
�Pur se of Buildin '
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P° S-�'Y�j^�`��11����'�/..�''d Utility Authorization No.
Existing Service,r,aqp_ Amps �Zc� ��Volts Overhead� Undgrd❑ No of Meters
f
New Service Amps 1 Volts Overhead� Undgrd� No. of Meters
� .IV�mber of Feec�ers and Ampacity
�, . � �
Location'and Nature of Proposed electrical Work: W2t'.S�s__=�_�,�,,�.�e �,�/,¢,...�-�
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Com letion o the o!lowin table m be waived the Iru or o W1re.r
"'� No.of Tocal
"� i - a 1 n Transformers KVA
No. of Li hcin Outlets No. of Hot Tubs Generators KVA
Above In- No.of Emergency Lighcing
�'"�+ No. of Li hcin Fixtures Swimmin Pool rnd. � rnd. � Bacce Unics
Jst,t
No. of Receptacle Oudets No.of Oil B�rners FIRE ALARMS No.of Zones
. Na oF Switches No.of Deteccion and
_� : No.of Gas Burners Iniciacin Devices
�,:
No.of Ranges No.oF Air Cond. Tonsl No. of Alercing Devices
Heat Pump Number Tons KW No.of Self-Contained
� No.of Waste Disposers Tocals: — — — Dececcion/Alerting Devices
� No. of Dishwashers �� Space/Area Heating KW Local � Municipal
Conneccion � Other
No. of D ets ecuuty ystems:
H; �' Heating Appliances KW No.of Devices or Equipvalenr
t A19.Q Water No.of No.of Daca Wiring:
,� Heaters KW Si ns Ballasts No.of Devices or Equivalent
N4. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
, No.of Devices or E uivalenc
"'' " ` Attach additional detail if derired,or a.r required by the In.rpector of Wire.r.
�INSURANCE COVERAGE:Unless waived by che owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability
� insurdnce including"completed operation"coverage or its substantial equivalenc.The undersigned ceni6es chac such coverage is in force,and has exhibiced proof
of same co che permic issuing office.
�CHECK ONB: INSURANCE� BOND� OTHER(� (Specify:)
"' Escunaced Value of Eleccrical Work: (Expi�acion Dace)
(When required by municipal policy.)
,J Work ta Statt: Inspections co be requesced in accordance with MEC Rule 10, and upon completion.
" I certify,under the pains and penalties of perjury, that the information on this application is true and complete.
IRM NAME: LIC.NO.
*' �,icensee: f�,,,,r��� Signature /'�� /' �J
� -fil�yd�G� G � LIC.NO./OL/.S"�Q
�;� (If applicable;enter exempt in the license number line.) Bus.Tel.No.: ,�3 --�s-„Z; '
Address: �� �yir�sx i2d. F�(�;�s��/��--�� Alc.Tel. No.: �3L,m�n?r
OWNER'S INSURANCE WAIVER I am aware chat the Licensee dces noc have che liability insurance coverage normally required by law By my signacure
below,I hereby waive this requirement.I and the(check one) owner� owner's agent.�
Owner/Agent
Signacure Telephone No.
': [Rev.04/G�1