HomeMy WebLinkAboutBLDE-21-000590 Commonweakh.el/ryamachuaslfe
' Official Use Only 5,
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✓ �. Permit No. f{ .11eParfnunf o` ti+c Jsrv�c�s
- `_r?_- 4 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 MR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: G /01- 7
City or Town of: �kg-MU L?fl To the Inspector of fres:
By this application the undersigned giv s notice of his or her intention to perform the electrical work described below.
Location(Street&Number) q W ?ti V it .
Owner or Tenant A Mt-isiink Telephone No. VJ14f$-'-(2l.,
. Owner's Address '/ U
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Cp 'Rr. . *1?
Purpose of Building Utility Authori- o, NoExisting Service Amps / Volts Overhead❑ Undg 1Ail
New Service Amps / Volts OverheadUndgrd lit" f.
0 g � A„ It.
Number of Feeders and Ampacity t /1
Location and Nature of Proposed Electrical Work: 1C in k cid yv.fiNT7 t Iiw W K to (J m,_ td #4,01
i)tS'1l ( Wi i N V 123.1A lifC
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
ZTransformers KVA
,j No.of Luminaire Outlets No.of Hot Tubs Generators KVA
V No.of Luminaires Swimming Pool Above ❑ In- ❑ No.ofLmergency Lighting
grad. grnd. Battery Units
4.1
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
—) No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.
of AlertingDevices
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 ❑ other
Connection
No.of Dryers Heating Appliances KW Security
of steres or Equivalent
s:*
No.of Water No.of No.of
Heaters KW Data Wiring:
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 Electrical Work: (When required by municipal policy.)
3
Work to Start: 0e, ( -Z-a-ta Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO RAGE: 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 0 OTHER 0 (Specify:)
n I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. c
'IP FIRM NAME: M�Q C v� L.. ��P.�� 1��CT�U G l LIC.NO.: ( O l)
Licensee: Signature LIC.NO.: 22 6 -A
�a `� (If applicable.enter "exempt"in the license number line.) Bus.Tel.No. L(7Yi' j
CS/I Address: ' 1
Alt.Tel.No.:
*Per M.G.L.c. 147. s. 57-61,security work requires Department 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 0 owner's agent.
Owner/Agent
Signature Telephone No. I PERMIT FEE: $,5 t(N