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I V E ommonwealth of Massachusetts Ofco firc�l^alUse Only /)
Department of FireServlces Permit No. r ^r)� q7v
1 2007 Occu aac end Fee Checked V J�
BOA D OF FIRE PREVENTION REGULATIONS [Rev. 11anc eFeblxnlc
i DEPT.
By:
N FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFO ATTON) Date: --Y—n? 3 '-0 7
City or Town of: _40 rmOt� To the Inspector of Wires:
By this application the undersigned gives not: • : of his or her intention to perform the electrical work described below.
Location (Street & Number) c29 N 1 O Ni Cf AI P D x111 Map Parcel
OwnerorTenant FJOPtA(f, )ATelephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes R1 No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service /00 Amps 2W 2 Volts Overhead Q Undgrd ❑ No. of Meters
N aw , ervice �_ Amps / f2 Volts Overhead ® Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
— --
No. of Recessed Fixtures
No. oPLig g Outlets
Lighting
No. of Lighting Fixtures
Na. of Cell.-5usp. (Paddle) Fans
Na, of Hot Tubs
ove n'0.
Swimming Pool rnd.grind.
Transformers KVA
Generators KVO'
o mergency Lighting
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS No. of Zones
o. o election an
No. of Switches
No, of Gas Burners
lnitiatin Devices
No. of Ranges
No. of Air Conti. Tons
No. of Alerting Devices
No. of Waste Disposers
eatPum um er ons _
Totals: _
0.0 e - onto e
Detection/Alertin Devices
Space/Area Heating KW
Local ❑ Connect al on Other
No. of Dishwashers
Heating Appliances pliances KW
ecunty ystems:
No. of Devices or E uivalent
No. of Dryers
0.0 ater K�
o. o o. o '
ct.,.,. Ballasts
Data Wiring:
I No. of Devices or Equivalent
INo of Motors Total HP ' �`"No. of Devices or Equivalent
No. I�ydromassage Bathtubs
OTHER:
Attach additional detail if desired or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue 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.
CIIECKONE: INSURANCE, BOND ❑ OTHER ❑ (Specify:)
(Expiration Dare)
Estimated Value of Electrical Work �S 7t�f� _ (When required by municipal policy.
Work to Start.' ,73 ZJ% inspections to be requested in accordance with MEC Rule 10, and upon completion.
• I certify, tinder the pains and penalties of perjury, that the inforination o t)tis application is true and complete.
FIRM NAME: LIC. NO.: e l
Licensee:rl l t y¢S SOl�)ii�/d% Signature LIC. NO.: .,
((f applicable, suer "exempt' in the license number line.) Bus. Tel. No., %��G
Address: Alt. Tel. No.
OWI%ZR'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
n,,,. OAoent — . . I PERMIT FF.F.: s ;fl