HomeMy WebLinkAboutBlde-20-001999 ,. p4. Commonwealth of Official Use Only
rE` Massachusetts Permit No. BLDE-20-001999
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/07]
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts E ctrical Code ( C),527 CMRR.()� C E I " E D
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ''`` CC Y
City or Town of: YARMOUTH To th Spector of Wires:
By this application the undersigned gives notice of his or her intention rtorm the electrical work 'bed below. OCT 3 1 201
Location(Street&Number) 6 GARDINER LN liltil
Owner or Tenant Telephone No. BUILDING DEPT.
Owner's Address , , , By-
Is this permit in conjunction with a building permit? Yes 0 No RI (C .•
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd 0 R- e
New Service 60 Amps 120/24( Volts Overhead 0 Undgrd 0 No.of Meters 1 �/
Number of Feeders and Ampacity 1 @ 60 amps
Location and Nature of Proposed Electrical Work: Verizon Small Cell Wood Pole Mounted Electrical Service On Utility Pole 6&7
1/2
Completion of the following table 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 '
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
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
___ Initiatinc Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: • ,Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local 0 Municipal 0 Other:
Connection
No.of Dryers Heating Appliances KW Security Systems:*
___„ „ No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Siens 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.)
Work to start: 10/14/2019 Inspection 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 same to the permit issuing office.
CHECK ONE:INSURANCE 0 BOND 0 OTHER 0 (Specify:) Yes
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: MARK J POTTER
Licensee: Mark J Potter Signature LIC.NO.: 18218
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:280 SOUTH ST,D/B/A POTTER ELECTRIC,DOUGLAS MA 015162717 Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License:
OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But
signature below,I hereby waive this requirement.I am the(check one) 0 owner 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE:$80.00
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