BLDE-21-000606 /
Commonwealth mmonwea[th el MagicLulls Official Use Only
0. r� /SZ1 rV 40�rO
fi 1�, = _ c�u,s Permit No.
eparenl o� —cervices
I' Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 Cilvill 12.00
(PLEASE PRINT IN INK OR TYPE INFORMATION) Date: C ;/ -'O
City or Town of: Years '>--I` k To the Inspector of Wires:
By this application the undersigned gives notice of his or her intentio to erform alp electtrtcl work described below.
Location(Street&Number) •7� II c�,`0 Cv l&
0.'• Owner or Tenant 2 ,t __
R , Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No Eg (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service tstXmps / Volts Overhead] Undgrd 0 No.of Meters
New Service 1S a Amps / Volts Overheads Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: y10/ci y i, }'
c ,(jUr 0`41' "f ! ' Lc ,.-
Completion of the followingtable may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Tr of Total
ansfo �--: �/ KVA
No.of Luminaire Outlets No.of Hot Tubs Gener , 0.-,
A1394
No.of Luminaires Swimmin Pool Above In- N "e + .g
No.of Receptacle Outlets No.of Oil Burners FI• ' . : ,I. AA
No.of Switches No.of Gas Burners No.of Dete on ,410
a V
Initiating D �/
Total
No.of Ranges No.of Air Cond. Tans No.of Alerting Dev' 4101
No.of Waste Disposers Heat Number Tons KW No.of Self-Contained
Totals: _ Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local ElMunicipal Other
Connection
No.of Dryers Heating Appliances I 'Security Systems:*
Na of Devices or Equivalent
No.of Water ICW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsfDeics Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desireek or as required by the Inspector of Wires.
Estimated Value of Electrical Work: z (When required by municipal policy.)
Work to Start 7/3o 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 same to the permit issuing office.
CHECK ONE: INSURANCE a BOND 0 OTHER ❑ (Specify:)
I certify,under the pains and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: A.lalt K I Signature LIC.NO.: Si..? 6
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:4-1S 0 7/St'?
Address: ,2 L y O.i,,. Sr N N.. ",`1L., A-i, s Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No.
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 I PERMIT FEE: $ vCci '
SignaturetuneTelephone No.