HomeMy WebLinkAboutBLDE-21-000515 Commonwsat+h o/111a oaehubtii6 Official Use Onnl
r� c� Permit No, Z' —cl> t c
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BOARD OF FIRE PREVENTION REGULATIONS r p)Occupancy and ve b eked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code tvjE �CMR 12.00
MATION)
(PLEASE PRINT IN INK OR TYPE ALL INFO Date: LL I[[
City or Town of: y�r,Ql�-r(. To the Inspector of Wires:
j...c_, By this application the undersigned Ives notice of his or her in tidescribed
to perform the electrical work below.
Location(Street&Nu ber) 5�(,�, 'v�
Owner or Tenant :e0 �Sik01�� T L`L .e.
Owner's Address �aG�eM4. j ;�
Is this permit in conjunction with a building permit? Yes No ❑ 4: f t
41 Purpose of Building 5�9 Uri n Utility Authorize , p4,hOp
ExistingService Amp I Volts Overhead 0 Undgrd n 1.ofte I� No.of Mete
New Service Amps / Volts Overhead 0 Undgrd❑ `�
,...,t,-, Number of Feeders and Ampacity O
Location and Nature of Proposed Electrical Work: lAj t f.A) Q k 5k9 /O( c L
} J
Completion of the following table mg be waived by the Inspector of Wires.
go.of Total 1
No.of Recessed Luminaires f No.of Ceil.-Soap.(Paddle)Fans Transformers KVA
No,of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires swimmingPool Above ❑ In- 0,rto.of>�mergency Lighting
CO grad, grnd. Battery Units
`�•' No.of Receptacle Outlets CNo.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners NO.of Detection and
,� Inidatina Devices
• No.of Ranges No.of Air Cond. Ton�sl 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 0 MuniciparCyyoa�ttnnection 0 Other
No.of Dryers Heating Appliances KW SectNo of Devices or Equivalent
No.of Water , No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP �TelecommunicationsofDvi quingg•
Na.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated ValueEtlec cal Work: (When required by municipal policy.)
Work to Start: 1 �f&a 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
it ce undersigned certifies that such coverage is in force,and has exhibited proof of sante to the permit issuing office.
�.t CHECK ONE: INSURANCE BOND 0 OTHER 0 (Specify:)
I certi y,under the ins and pe fti.is of perjury that the...Information on this application is true and complete.
0)0'`0 ei FIRM NAME: (tC✓1 I' tT'c it LIC.NO.:c506 -0
icensee: GI1 u Signature LIC.NO.:`D' �/,/r,' applicable, 7' pt"i jhe license n ber tine.} Bus.Tel.No.: coV 2- X06
II VA 1:749 M' Address: C W raN� NIit9 �alstf�� titom? AIt.Tel.No.:
�l *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. 1 am the(check one)0 owner 0 owner's agent.
Owner/Agent PERMIT FEE;$ ;
Signature _ , Telephone No.