HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
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All work ro be performed in accordance with the Massachusetts ::1eccrical Code, (MEC), 527 CMR 12.00
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(OFFICE USE ONLY)
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.,, y .- PERMIT 140. E-6-7
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(PLEASE PRINT IN INK OR TYPE i e,:-..,-:,:.• Date: . .;"1/
To the Inspector of Wires: By this application the undersigned gives notice of his or her intent on to erform the electrical
work described below. r L. 1� \ �4 p^ ` �
Location(Street&Number) � G/M PL i
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Owner or Tenant Sc2 1/ X. Telephone No.
Owner's Address -5 1 4S ,t lQ iV 8
Is this permit in conjunction with a building permit? El Yes ONo (Check Appropriate Box)
Purpose of Building . Utility Authori2 ation No.
Existing Service Amps / Volts Overheadlj Undgrd CI No. of Meters
New Service Amps / Volts OverheadE Undgrd CI No. of Meters
Number of Feeders and Ampacity
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Location and Nature of Proposed electrical Work: `iJ j R .le, 5 'estgitis,
Completio f of the following table may be waived by the Inspector of Wires
No.of Total
No, of Recessed Fixtures No. of Ceil.-Susp,(Pad&IFans Transformers KVA
No. of Lighting Outlets No. of Hot Tubs Generators KVA
, Above r .i In- No.of Emergency Lighting
Q No. of Lighting Fixtures Swimming Pool grnd. grnd. Battery Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones
No. of Switches No. GasBurners No.of Detection and
6.L: of Initiating Devices
No. of Ranges No. of Air Cond. Total
Tons No. of Alerting Devices
No. of Waste Disposers Heat PPump
ap: I Number Tons KW _ No. of Self-Contained
-Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local 71 Connectioniectio n 0 Other
Co
No. of Dryers Heating Appliances KW Secutity Systems:
No.of Devices or Equipvalent
No.of Water No.of No. of Data Wirin :
Heaters KW Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
Attach additional detail fl desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of elect'ical work may be issued unless the licensee provides
(,proof of liability insurance including"completed operation"coverage or its substantial equivalen. The undersigned certifies tha such coverage is in
force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND n OTHERS (Specify) 4YeA4 9Mfi.? / O
(Expirati Date)
Estimated Value of Electrical Work:
(When required t y municipal policy.)
c.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
N I certify,under le •ains and ,-.1 'e •f perj ,that ,- info .tion on this applicatio 1 is true and complete.
P.- FIRM NAME: r e a' i 1� c,�►' i�i. r LIC.NO. ����
Licensee: Signature`'T.:-ii � LIC.NO.
c n (If applica e e ter"exem t" in a lice ber lin ��"� / Bus,Tel. No,; � 36:9
�f1/4l Address: rtt LL 1 o do . . _Alt. Tel. No.: �'� 7 $
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the Lability insurance coverage normally required by la .By my signature
below,I hereby waive this requirement.I am the(check one)owner El owner's agent.
Owner/Agent
Signature Telephor e No.
[Rev.04/00]