HomeMy WebLinkAboutE-04-784APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Mamchusem Electrical Code, (MEC), 527 CMR 12.00
(OFFICE USE ONLY
�JI' Rn 0 By —
Fee: $S�
A7�R"1 5 2004 �J
PERMIT NO. / S�
BUILDING DEPT, _
(PLEASE PRINT IN INK Oft"'"T E AU ' IFOR L4VON) Date: /" 40 V
To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical
work described below.
Location (Street & Number) I 5 ( L-_l Lf)
Owner or
Is this permit in conjunction with a building permit? Q Yes MNo (Check Appropriate Box)
Purpose of Building / v Utility Authorization No.
Existing Service ¢ Amps 20 Volts Overhead Undgrd Q No. of Meters
New Service Amps /ZO / A 4D Volts OverheadO Undgrd Q No. of Meters
Number of Feeders and
Location and Nature of Proposed electrical
Camnletian of the fallax•inP table may be x aived by the Insnector of Bires
No. of Total
of Recessed Fixtures
o of it - addl Fans
Transformers -KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
Above n-
Q
No. o Emergency Lighting
No. of Lighting Fixtures
Swimming Pool gmd. gmd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches -
No. of Gas Burners
o. of Detection an
Initiatin Devices
No. of Ranges '1
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers G
Heat mp
Totals:
um r
— —
-loss-
—
— —
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Spg ace/Area Heating KW
Local Q Municipal Connection Q Other
No. of Dryers
rY
Heating Appliances KW
g PP
Secutity Syystems:
No. of Devices or ui valent
No. of Water
No. of No. of
Data Wining
Heaters KW
Si Ballasts.
No. of Devices or Equivalent
No. H dromassa a Bathtubs
Y g
No. of Motors Total HP
Tel No capqons Wiring:
No. ic-or Equivalent
O
Attach aaattional detail tf aesirea, or as required by the inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit 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 certifies that such coverage is in
force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND[] OTHERQ (Specify:)
(Expiration Date) '
Estimated Value of Electrical Work: �� (When required by municipal policy.) r
%� Work to Start: S ef/ fAiC-- Inspections to be requested in accordance with MEC Rule 10, and upon completion.
kZ I certify, under the pains aad penalties of perjury, that the information on this application is true and complete.
`FIRM NAME: ✓'I S /} /tih ! [ GGT✓YGA / LIC. NO. 33 6 %D
M Licensee: Cam► �.S 4�y vQ Signature LIC. NO. -M. _( 76 F
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:.3 Z. Co -eS/'%/�%
Address: 9 Z.3i&� ,;-e✓"GliGL.% 5,cZ4 CO U.0 Alt. Tel. No.: 3 4 `t 609' 7
\OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature
low, I hereby waive this requirement. I am the (check one) owner owner's agent.
be
Owner/Agent
Signature Telephone No.
(Rev. 04100]
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