HomeMy WebLinkAboutBlde-21-000462 (..ommonwea/th o/MaJoachweth � Official Use Only
'' { e't c� cc77 Permit No. a � _(0,LAG Z
E - AI' 3epartment o� lire�eruiced
j, ? Occupancy and Fee Checked
''�. 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),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -7 " ..39 c)O
City or Town of: .164 Oar-07660Th To the Inspector of Wires:
By this application the undersigned gives noe of his or her intention to perform the electrical work described below.
Location(Street&Number) 0258/ee ,Ltz/9e.."
Owner or Tenant figiaN42220aae, M f' n/ et5 Telephone No. �-- - -7
Owner's Address i 2 Ji�e-r a(GL./7.- �J
Is this permit in conjunction with a Ibuilding permit? Yes ❑ No Er (Check App4 x)l/
Purpose of Building Ce.-S tQ( - `11.113C0- Utility Authorization N o 23
Existing Service Amps / Volts Overhead ❑ Undgrd❑ 1.
New Service Amps / Volts Overhead❑ Undgrd ❑ Ni ,_
4.).
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: kwv-e_ \.\\ -gyp G(:)&R. w• , 41641P
10(:)•A cab pa.Xle�.
Completion of the followin&table may be waived by the Inspector of Wires.
Total
No.of Recessed Luminaires 8 No.of Ceil:Susp.(Paddle)Fans 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 /j No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches In
No.of Gas Burners No. Detention and
Initiating Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting
Devices
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❑ Municipal Connection ❑ Other
. No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters 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 Ele 'cal Work: /0,d�-When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
q.. )
INSURANCE OVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
c;"" (/AD the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
1 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
1 (''
/ CHECK ONE: INSURANCE 0 BOND El OTHER ID (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: .i\\\o r, `4 `\ �'.e rt LIC.NO.:
Licensee: J�re K . /4 fr, /j/1 Signature �1 toki;014,1A,„ LIC.NO.: t.(`
(If applicable, nter "ggem t"in the license number fine.) Bus.Tel.No.:,3 -73.3 87
Address: ' .
- o/p/I/— AR . # re'/4 fig- 0-0?5 Alt.Tel.No.:
*Per M.G.L.c. 147,s.57- ,security work requires Departmentof Public Safety"S"License: Lic.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)❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $