HomeMy WebLinkAboutBLDE-21-000499 Commonwealth of Massachusetts Official Use Only
it—= l Permit No.
�t=• Department of Fire Services
_:�=�9
—.44 Occupancy and Fee Checked
J= I BOARD OF FIRE PREVENTION REGULATIONS
,,�— [Rev.9/OS] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I ZZ fi ,°
City or Tow' of: ' To the Insp ctor of Wires:
By this application the undersigned 'ves notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 520 I ,yt,(. -T✓,S t-14y.A
Owner or Tenant�PcUkt, �1,., Yi {� S-{-Zi,".rj pp 3 Telephone No.5 5 SC/ (,
03'
Owner's Address j4N-0,-e_
Is this permit in conjunction with a building permit? Yes n No n (Check Appropriate o )
Purpose of Building Utility Authorization
Existing Service Amps / Volts Overhead n Undgrd It*
New Service Amps / Volts Overhead n Undgrd'.. ,/� e
Number of Feeders and Ampacity `��
Location and Nature of Proposed Electrical Work: R(Lit pt.-Lt._ Qftvc-T 'c) v„.„A-1- 4111 tie D
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
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- No.of Emergency Lighting
No.of Luminaires Swimming Pool grad. ❑ grad. ❑ Battery Units
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
l
No.of Ranges No.of Air Cond. .Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained
P Totals: _..._...,......__..._...__. Detection/Alerting Devices
Municipal
No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other
HeatingAppliancesVecurity Systems:*
No.of Dryers PP KW No.of Devices or Equivalent
No.of Water Kam, No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
Telecommunications Wiring:
No.Hydromassage Bathtubs No.of Motors Total HP 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: IA'S Inspections-t ie 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.
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FIRM NAME: / ,fr 4i 1 Q,vf-1r1(.- T.1'r'vc_ LIC.NO.:
Licensee: at,, n'l tj(liR. S Signature __G LIC.NO.: / 5?-O k
(If applicable, enter "exempt" in the license number line.) Bus.Tel.No.:sb 9 776 96 5�
Address: 1 D ()d)c. 3..►3 51 j A-(wok I M A O 7—S.`IAlt.Tel.No.:
*Security System Contractor License required for this work;if applicable,enter the license number here:
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) ❑ owner ❑owner's agent.
Owner/Agent PERMIT FEE: $ NO—'P.(,
Signature Telephone No.
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