HomeMy WebLinkAboutBLDE-21-000548 (
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Permit No. l'iZl -�S 4
BOARD OF FIRE PREVENTION REGULATIONSY Fee Checked
[Rev. 1/07] cave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Masxaehusetts Electrical Code(ME ,7?CMR 2.00
(PLEASE PRINT IN INK OR TYPE LL ORMATION) Date: / a 0
qCity or Town of: q/Ivt 0 c -114 To the I ee or of
By this application the undersigned gives ofcece P��the electrical workhis or her intention to tees:
.Y. Location(Street&Number) descn`bed below.
(p4 th A-Y f Cav"- Tit k-A-CtF-
Owner or Tenant 3'ftt.ts (4 1 L fill
Owner's Address Telephone No. S 3 131
Is this permit in conjunction with a b J
n uBding permit? 'Veda No 0 (Check .
Purpose of Building 1���j ?. ,
p �!�� Utility Authorization N
Existing Service Amps / Volts Overheard
New Service ❑ Undgrd 0 No.of Meters
� _ Amps t' i Volts Overhead . Undgrd
g- Number of Feeders and AmpachyW / ❑ No.of Meters
Location and Nature of ` f ��` '�'pmad Electrical Work:Zet."G-t. D .�°� loor.., ----
� ��� '1 S "�l( I
O Completion of the following table m be waived by the In for of Wires.
No.of Recessed Luminaires No.of Cell-Snap.(Pad[ )E Na.of Tabs
in
Transformers
�`
No.16 of Luminaire OutletsKVA
No.of Hot Tubs Generators KVA
_ No.of Luminaires Swimming Pool � e ❑ Ind"d. ❑ Battery U tsency Lighting
`"� No.of Receptacle Outlets
No.of Oil Burners FIRE ALARMS lNo.of Zones
No.of Switches No.of Gas Burners No.of Detention and .
t No.of RangesTotal
Initlathy Devices
No.of Air Cond. No.of Atoning Devices
Tons
No.of Waste Disposers 'RentlPump I Somber Mons 1KW M No.of Self( .DetecdonNedixi-Contained
No.of Dishwashers Devices
Space/Area Heating KW Local❑ Mun cell
Other
I CaaanecHon
No.of Dryers 0
Heating Appliances KW
Security Syyan **
No.of Water , No.of No.of Devices ar Equivalent
Heaters No.of Data Wiring:
No.Hydrn Signs Ballasts No.of Devices or Equivalent _
massage Bathtubs No.of Motors Total HP 7'Hecommnnica#ono
OTHER: Na.of Device:or EUWu�ent _
,c,ei ..- d� Attach additional detail ifdesired or as required by the
Estimated Value ectri Work: Inspector of Wires.
_^e 4� Work to Start: � (When required by municipal policy.)
„1 INSURANCE COVE ti ns to be requested in accordance with MEC Rule 10,and
S ;. . lam' GE: Unless waived by the owner,noupon workco maytiss
`� the licensee provides proof of liabilityngpermit for the performance of electrical may issue unless
undersigned certifies that such coverage in insuranceorce,and has exhibited operation"o sameto coverage or its substantialssuinequivalent. The
CHECK ONE: INSURANCEproof of to the permit issuing office.
,,,.
I cer�fy,under the patios and 0 OTHER 0 (Specify:)
.G „y FIRM NAME: f �►that the lxf riwa:kmCT on application is true and ccrerrpJe+re.
�l�l11411-4Licensee: �Lam` LIC.NO. .��.�L_
� (/fgpplicabfe,ent Signature
O` sin the license number ti LIG.NO.:
Address: /tf. D e Gam'. v.,� Bus.Tel.No.: -- i 1-3 l 4)
*Per M.G.L.c. 147,s.57-61,security work arcsety Alt,TeL No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee notno th License: insurance coverage normally
n required by law. B m
,- Owner/Agent Y Y si$nature below,I hereby waive this requirement. I am the(check one A owner ■ owner's ..ent.
Ce 1 Signature
Telephone No. PERMIT FEE:$ 2-36
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