HomeMy WebLinkAboutElectrical Permit 4; r� The Commonwealth of Massachusetts Irrn t b. �1
`� /(�p� ! ' Department of Public Safety
1 ." %V W d Occupants S Fee Checked
V R c
e3
N. �� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 ileave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 ---
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date f�ri Jp l n1\
City or Town of Yar .to u-i-i. To the Inspector of +h+lples: r I
The undersigned applies for a permit to perform the electrical work described below. 1 !� 71^ I ;,
I f ;�‘l 0 1999 i �,
Location (Street S Number) 78 �PiT /3e s e- /4. 11 /� —I
Owner or Tenant .(JP.-cl E 1�7 �'�t C I��C�J o $��� 7..� __----1
Owner's Address
Is this permit in conjunction with a building permit: Yes ❑ No pC TChetht Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters_
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity rr
Location and Nature of Proposed Electrical Work )✓'C4( Seltl s- fit( C`iae...e LP Irti`
Total
No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA
Above In- A
No. of Lighting Fixtures Swimming Pool grnd. ❑ grnd. ❑ Generators
No. of Emergency Lighting
No. of Receptacle Outlets No. of Oil Burners Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
Total No. of Detection and
No. of Ranges No. of Air Cond. tons Initiating Devices
Heat Total Total No. of Sounding Devices
No. of Disposals No. of pumps Tons KW
No. of Self Contained
No. of Dishwashers ' Space/Area Heating KW Detection/Sounding Devices
❑ Municipal ❑Other
No. of Dryers Heating Devices KW Local Connection
No, of No. of Low Voltage
No. of Water Heaters KW Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP 1//'D
OTHER: /
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES[} NO ❑ I have submitted valid proof of same to this office. YES® NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
D. t INSURANCE ❑X BOND ❑ OTHER ❑ (Please Specify) 1/1/2000
(Expiration Date)
r�
�., Estimated Value of Electrical Work $ G 00
P
Work to Start
Inspection Date Requested: Rough Final
Signed under the penalties of perjury:
'' FIRM NAME Steven D. Robbins =Master Electrician ���s LIc. NO._____
Sty. /Lv( . 13945-A
Licensee Signature
LIC. N0.
1 Bus. Tel. No. (rag) 437-5228
Address 38 Church St. ,Harwich,Ma. 02645 Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
• stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
D application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
(Signature of Owner or Agent)