Blde-21-006345 cf Commonwealth of Official Use Only
Massachusetts Permit No. BLDE-21-006345
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 Electrical Code (MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:5/4/2021
City or Town of: YARMOUTH To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to pertorm the etectncal work described below.
Location(Street&Number) 259 OLD TOWNHOUSE RD
Owner or Tenant NUGENT NORMA L Telephone No.
Owner's Address 259 OLD TOWN HOUSE RD,WEST YARMOUTH, MA 02673
Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd 0 No.of Meters
New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Recessed lights&kitchen&bathroom receptacles.
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
Initiatine 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/Alertine Devices
No.of Dishwashers Space/Area Heating KW Local 0 Municipal ❑ 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: 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:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Thomas A Umbrianna
Licensee: Thomas A Umbrianna Signature LIC.NO.: 38324
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:22 BOW ST,CARVER MA 023301230 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: $75.00
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Commonwealth ol Mamachudettd Official Use Only
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1111 t department o/. +ire Serviced Permit No.
-- 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 ORT, ' E ALL INFO'4 •T/IN) Date: . -2o '2
City or Town of: tta, To the Ins ector o
����J V p Wirers:
By this application the undersign gives notice of his or, er intention to perform the electrical work described below.
Location (Street&Number)yc OLD—TOW/4 -HOME
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box
)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd g ❑ No.of Meters
New Service Amps / Volts Overhead❑ f Undgrd g I No.of Meters
Number of Feeders and Ampacity
Location andNature of Proposed Electrical Work: %op l?(C > 14 fi` b1A� L
CG l 1 "� A A. �/rJ d
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 INo.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump I Number I Tons l KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection El Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of Devices or Equivalent
No.of No.of
Heaters KW 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: 35770 (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 s m force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) /
I certify,under the pains and p na 'es of erjury,that he information on this application is true and complete
FIRM NAME: '7 1 0, / Le C,i(�'/ P LIC.NO.: 3
Licensee: Signature LIC.NO.:
(If applicable,en er"exempt"in the license number line.)
Address: Bus. Tel.No.:Tel.No.:7At/ -Jb�
*Per M.G.L. c. 147, s. 57-61,security work requires Department of Public Safety"S"License: Alt.Lic. No. Q`
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 a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ *
(6(6 2 sy. 6) 2.- 6G'
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