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Commonwealth of Massachusetts Official Use only
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i 4 Department of Fire Services Permit No.
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BOARD OF FIRE PREVENTION REGULATIONS [RevOcc.up9/07)cy and(leaveFee blank)Checked
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 TYP ALL INFORMATION Date:
City or Town of: �i,([Bc1-r�l To the Ins -.. •.- .
By this application the undersigne gives notice of his or her i tention to p rform the electrical wo ' • •-.
Location(Street&Number) ,3Bi) /r� 1-5/ad i-i' 5vc/,Df„A 1ZZ tbio- I 4 I`�G.•�
Owner or Tenant SU II;Vg 4 -1-4_6 M4-_s Telephone 'o.
14.07
Owner's Address same I 'IG
Is this permit in conjunction with a building permit? Yes & tto
❑ No (Ghee ,,, o. ' .:-• :• ,
Purpose of Building Utility Authorizatio No. �E' t
Existing Service /00 Amps Pie Volts Overhead ID Undgrd No.of Meters
New Service /aO Amps /1e AO Volts Overhead❑ Undgr .^ pitallo.of Meters
Number of Feeders and Ampacity ,2 rg4Je/5 /Bo .4.115 2- 'It_ 2_83 8.
Location and Nature of Proposed Electrical Work: dJ%cl) ud 4 __ �, ��� .
`""�! , •.,; cry
Completion of the following table may be waived by the Inspector of Wires. • r 41, if low
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.o )Ilr
Transformed
No.of Luminaire Outlets No.of Hot Tubs Generators 4#4
0'
No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting
grnd. grnd. Bad Units
-
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS f No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
Tota
No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices
No.of Waste Disposers Heat Pump I Number Tons KW 'No.of Self-Contained
Totals: (__.�.__......_.... �...._._...._�..
Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW LocalMunicipal
❑ Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of No.of Devices or Equivalent
Heaters KW No.of 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.)
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 BOND 0 OTHER 0 (Specify:) Merchants Insurance
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: R&S LaFleur,LLC LIC.NO.: 16814A
Licensee:Raymond E.LaFleur Signature LIC.NO.: 15675E
(Ifapplicable,enier"exempt"in the license number line.) Bus.TeL No.:50$-775-6814
Address: 45 Plant Rd; Unit# 101;Hyannis,MA 02601 Alt.TeL No.:508-775838
*Security System Contractor License required for this work;if applicable,enter the license number here:
OWNER'S INSURANCE WAIVER: lam aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner 0 owner's agent.
Owner/Agent
Signature Telephone No. I PERMIT FEE:$ — I