HomeMy WebLinkAboutBLDE-19-005459 (2) C0 11711 3 0 1ZWtalth of/rla ac sl#s Official Use Only
`0' 2 �...�ire Service? Permit No. l��{ l
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' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked)
•'�•`: [Rev. 1/07) (leave blank)
APPLICATION 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 INFORMATIO19 Date: 4 ( iG
City or Town of: YARMOUTH 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) CO GAM-VEAL
_ (2.3 , -
Owner or Tenant c'12_, , T3Ei j k.g--X Telephone No
Owner's Address "7 �l l 0 `T N..‘O2t.t�Y L c') t1 5j ep ( i
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building t&€j. )( X:Ay' iir_rA� Utility Authorization No.
Existing Service Amps / Volts Overhead ❑_ Undgrd❑ No.of Meters
New Service Pkices Amps ,((6/ atag Volts Overhead Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: `
(AC.
Completion of the following table may be waived by the Inspector of li ires.
No.of Recessed Luminaires No.of Ce�1.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets ( ) No.of Hot Tubs Generators KVA
No.of Luminaires Swimmin pool Above In- No.of li.mergency Lighting -
g =rod. ❑ grod. ❑ Battery Units
No.of Receptacle Outlets 3 No.of Oil Burners FIRE ALARMS JNo.of Zones 1
No.of Switches a No.of Gas Burners ( . No.of Detection and
Initiating Devices
No.of Ranges No. of Air Con `� TO r�
_� Tons�cX No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons No.of Self-Contained
Totals:I I Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local 0
Connection Municipal '
❑ Other No.of Dryers Heating Appliances , Security Systems:*
No.of Devices or Equivalent
No.of Water No.of
Heaters KW No.of Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.H dromassa a Bathtubs Telecommunications Wiring:
y g No.of Motors Total HP
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
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 cove a is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER 0 (Specify)
I certify, under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM N
LIC.NO.:
Licensee: , �L A. y�s► ��
. Signature 1 LIC.NO.: r' ? 'y
(If applicable,enter "exempt in the licence nb�1�e�.), �`.-
Address: a(� �� ( `, -7[u V, ,n �, Bus.Tel.No.: to �,
J *Per M.G.L. c. 147,s.57-61,security work requires artmntofYPublic Safety t� Alt.Tel.No.: {'`"'`�
�z
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not havethe liability insurance coverage normally
S required by law. By my signature below,I hereby waive this requirement. I am the(check one ❑owner ❑owner's a eni
Owner/Agent
Signature. Telephone No. PERMIT FEE: $