HomeMy WebLinkAboutBLDE-21-000498 k.
i, A. l.omawnwsa/L! 01 Mattsadutsatio Official Use Only
ci 0. ., c-� c7 Permit No. (3''Z l (0 4 [t )
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' 2) .fir+ iwtc�t 1 •partSn.nt o� Occupancy and Fee Checked
,. t :' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (leave blank)
v 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 TTE,ALL INFO TION) Date: 3"2 0
City or Town of: rub a LA To the Inspector of Wires:
By this adersigned ves o01 or h intention to perform the electrical work described below.
Locationpplication(Street&the Numunber) ' n
Owner or Tenant SD/e-v i024is Telephone No. 3 0/ - 3 Yb/9‘7
I Owner's Address ►�
Is this permit in conjunction with building permit? Yes 0 No (Cheek r",4. ,,,,,.,: �/
�� Purpose of Building o 1",, Q.,-,Z mac. 1 Utility Authorizatio 1 '� `.
?...„
Existing Service Amps / Volts Overhead 0 U- ndgrd .iip
New Service Amps / Volts Overhead U- ndgrd❑ No. OP'
p ❑
Number of Feeders And Ampacity
Location and Nature of Proposed Electrical Work: k �-e- YZ'r l�,C�yyre' ?f r
Completion of the followin table nip be waived by the I for of Wires.
No. TotaI
No.of Recessed Luminaires No.of CelL-S (Paddle)Fans Transformers KVA
°� KVA
No.of Luminaire Outlets No.of Hot Tubs Generators ( KVA'Z Z
No.of Luminaires SwimmingPool Above In- ❑ No.or Emergency Ltighttng
trod. grnd. Battery Units
No.of Receptacle Outlets No.of 011 Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners 'No.o?Detection and
` Initiating Devices
1 IL' No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
rs Heat Pump Number. Tons KW 'No.of Self-Contained
No.of Waste
Totals: _KW Detection/AlertinDevicea
No.of Dishwashers Space/Area Heating KW 0 C nnectlon 0 Other
NorDryers of Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water , No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.H dro Bathtubs No.of Motors Total HP Teleeo of Devi esons VV�nngg•
Y e No.of Devices or Equivii7ent
1*Os.-' OTHER:
Attach additional detail if desired or as required by the Inspector of Wires.
C0 /,1,a Estimated Value El tric Work:
0./ (Whe required by munic lic .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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE El BOND 0 OTHER 0 (Specify:)
,,,,,.(-.-- -' I cerllfy,under the pains and penalties of perjury,that the information on this application is true and complet '
(t FIRM NAME: LIC.NO.: cZ l�'i Z�
SNo r Licensee: if , ,% __ Signature�- LIC.NO.: g 2. Z4
(If applicable, ter,".. .t" the li e r e. -7V (S 6- 7 7>6
t 7 ?� r ) Bus.Tel.No.: d
of tl" Address: 0 t /d r G Ol6f�j Alt.TeL No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department f Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: 1 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
Signature Telephone o. PERMIT FEE:$ 7 cvd