HomeMy WebLinkAboutElectrical Permit 1
Commonweal of 7/17addachasetto Official Use Only
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• _., t arpartmsni o`giro Spoked Permit No.
= Iv Occupancy and Fee Checked r
%.;.,.---_---/ BOARD OF FIRE PREVENTION REGULATIONS [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),5 7 C R 12.00
(PLEASE PRINT IN INK OR TYP3 AL INFOR TION) Date: / /717
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City or Town of: I. � To the Inspector f fires/
By this application the undersigned gives notice of his or her intentio to perform the electrical work descr
Location(Street&Number) 3g. G _ '! ' -��
E2-2-34
Owner or Tenant Mie k Telephon No. yy ., ; ,j
41 ,1 eJ
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appr l -0 a . '
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead 0 Undgrd❑ No.of Meters
New Service Amps / Volts Overhead 0 Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: [ v v5%
Completion of the followingtable may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA _
, No.of Luminaire Outlets No.of Hot Tubs Generators KVA
`� Above ❑ In- ❑ No.of Emergency Lighting
No.of Luminaires Swimming Pool
grnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
�,No.of Switches No.of Gas Burners No.of Detection and
`� Initiating Devices
Tot
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number .Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
s,_, No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ �
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water No.of No.of
KW
Heaters Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
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.)
NIWork 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 coverage is in force,and has exhibited proof of sa a to the permit issuing ofcy.
4 CHECK ONE: INSURANCE BOND 0 OTHER 0 (Specify:) En7L`7 l 672—
I certify, under the a' 4nd1 ies o erju ,that thin rmation o this app icaatt'ion is true and comp lete.
IRM NAME: C � t5 � � LIC.NO.: -,3lva�0
Licensee: Signature � i.'Il LIC.NO.:
f applicable, p!er " em t"in t e number li Bus.Tel.No.: Sol?"' Navy
Address: fZ7 (� j A., G(/Ci 0�7�- Alt.Tel.No.: 1 7374
c���;� *Per M.G.L. c. 147, s. 57-61,security work requires Department of Public Safety"S"License: Lic. No. ���
.J) OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent.
Owner/Agent OD
Signature Telephone No. ` PERMIT FEE: s 5,OU -