HomeMy WebLinkAboutBlde-21-000461 Commonwealth 1 Official Use Only
* ommonurea o a�ac uastta +�L�
o' lit _ t 1 Permit No.
e department o ._tire Jeruicea
t c-5.1 Occupancy and Fee Checked
y,,.�y4,�' 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 ME��S�CMR 12.00
(PLEASE PRINT IN INK OR TY ALL ORMATION Date: / 15
City or Town of: +, To the Inspector of Wires:
By this application the undersigned gives no o his her intention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant Telephone No.33 - 93.3-/q87
Owner's Address CS el-as --
Is this permit in conjunction with a building permit? Yes ❑ No V (Ch k • 616 : Box)
Purpose of Building Q�hVa%„ Utility Authorizatio . l^
Existing Service Amps / Volts Overhead ❑ Undgrd 40!
New Service Amps / Volts Overhead❑ Undgrd ❑ 1.A
L6. , it 8,p,
Number of Feeders and Ampacity O
P h'
Location and Nature of Proposed Electrical Work: csOp‘y‘Q, ems, - w`CQ i'g 44:k5),F,
Completion of the followin&table may be waived by the Inspector of Wires.
tal
No.of Recessed Luminaires f No.of Ceil.-Susp.(Paddle)Fans Tf
Y� Trranosformers 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 v)- No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches 4. - No.of Gas Burners No.of Detection andInitiating 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❑ Municipal ❑ r
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 Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunicaions Wiring:
No.of Devicet s or Equivalent
OTHER:
nn Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of lectri al Work: GO/ (When required by municipal policy.)
Work to Start: 74719490 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: \ tyres `-r \\ �1e c-t LIC.NO.:
Licensee:ct 7C j k, lr/'fih///l Signature +3 k LIC.NO.:a t'y6 oZ
(If applicablee enter " xempt"in the license number•�ine.) �r Bus.Tel.No.:3 -733-fa8�
Address:0 c I/Iic A7d . )'IY6,-oxP irk. UC)c' Alt.Tel.No.:
*Per M.G.L.c. 147,s.57- ,security work requires Departmen of 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)0 owner ❑owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.