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APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
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$ r (OFFICE USE ONLY)
' P-"- _.._ TOWN OF YARMOUTH By 4 L-
= Fee: $ :6--a
, toe/-7Gt76 0 PERMIT NO. E _6 5 — r.,,-,1
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(PLEASE PRINT IN INK OR TYPE ALL INFORMAWN) Date: )/ 0S
- To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to p- • . the electrical
work described below. Q "'
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Location(Street& Number) ' 0 G c h--1-1 (Z t3 e_-
Owner or Tenant V e s c.E DEC 02 igwone No. QAC4.00
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Owner's Address MA. 'Q..- ✓""
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Is this permit in conjunction with a building permit? U Yes ANo (Check Appropriate Box)
Purpose of Building „�,. c.0-4241 i A.( Utility Authorization No.
Existing Service f°0 Amps 11 0 / 74,0 Volts Overheat"►i Undgrd 11 No. of Metiers I
New Service Amps / Volts Overhead Undgrd 0 No. of Metiers_
Number of Feeders and Ampacity
Location and Nature o, oposed electrical Work: l �b'Zit.i 9---C 1, itC,v LZ c f e)
S eV-CAL, icy 1-4,P T A- /9- 2-AK-
Completion of the following table may be waived by the Inspector of Wires
No.of Total
No. of Recesses 'xtures No. of Ceil.-Susp.(Paddle) Fans Transformers KVA
No. of Lighting Outlets No. of Hot Tubs Generators KVA
Above In- No. of Emergency Lighting
No. of Lighting Fixtures Swimming Pool grad. grad. Battery Units
1111w—
No. of Receptacle Outlets No. t •it Burners FIRE ALA' L A
No. of Zones
No. of Switches No. of Gas Bu s .No : •etection and
Initiating Devices
No. of Ranges To •
g No. of Air Cond. ons No. of Alerting Devices
eat Pump N o' W No. of Self Contained
No. of Waste Disposers ��Toot�tals — _——Detection/Alerting Devices
No. of Dishwashers ��ce/Area Heating KW Local E Municipal
Connection LI Other
No.of Dryers Heating Appliances KW tity Systems:
s f Devices or Equipvalent
No.of Water No.of No. of Data Win _•
Heaters KW Signs Ballasts No.of i- :-s or Equivalent
wt No. H s -. assage Bathtubs No.of Motors Total HP Telecommunication icing:
No.of Devices or v'6...valent
.46
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Attach additional detail if desired, or as re ili;t e 1 : ,.a
v $t f ices.
�NSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work maybe 3 �-unless the lic ..
proof of liability insurance including"completed operation"coverage or its substantial equivalent. Theispies
force,and has exhibited proof of same to the permit issuing office. q undersigned ICtfies that such c,werage in
CHECK ONE: INSURANCE PI BOND 0 OTHER (Specify:) 1 �i7b
Ia.piration Date)
CV-Estimated Value of Electrical Work: $1 D0 � (When required by municipal poli se-. ----._
Work to Start: — Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the painkand penaltigs of perjury{ that the information on this application is true and complete.
FIRM NAME: L.,;14 O- t( .eG'r&{„t(.. LIC. NO. ,%-f5 (p 4
Licensee: �, �. t-�l�,�(T Signature r 1). / LIC. NO. 3 pt2 34
(If applicable, enter"exempt" in the license number line.) / Bus. Tel. No.:
44-address. O X- l?i..or0 '1/43 ,GA 0---1 . 171 A e ()eke t Q Alt. Tel. No.: 50 8 "4.(x1 AA 33
OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance coverage normally required by law.Hy my signature
below,I hereby waive this requirement. I am the(check one)owner El owner's agent.0
Owner/Agent
Signature Telephone No.