HomeMy WebLinkAboutBLDE-21-004804 of Commonwealth of Official Use Only
E Massachusetts Permit No. BLDE-21-004804
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/07]
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 TYPE ALL INFORMATION)
City or Town of: YARMOUTH DaTo the te: Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 17 MOSS RD
Owner or Tenant PETROWSKI JOSEPH H
Owner's Address 66 ARNOLD RD, WELLESLEY, MA 02481 Telephone No.
Is this permit in conjunction with a building permit?
Purpose of Building Yes 0 No 0 (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps Volts Overhead 0
New Service Undgrd 0 No.of Meters
Amps Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: generator installation w/5'trench
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
Transformers Total
No.of Luminaire Outlets KVA
No.of Hot Tubs Generators 1
KVA 22
No.of Luminaires Swimming Pool Above ❑ In- ElNo.of Emergency Lighting
grnd. grnd. 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
No.of Ranges No.of Air Cond. Total
Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump I Number I Tons I KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal
Connection 0 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:
Siens Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or Equivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to start: 04/01/2021 (When required by municipal policy.)
Inspection 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 0 BOND 0 OTHER 0
:)
I certify,under the pains and penalties ofperjury,that the information on this applicationyis true and complete.
FIRM NAME: RANDALL C AGNEW
Licensee: Randall C Agnew
Signature LIC.NO.: 17492
(If applicable,enter"exempt"in the license number line.)
Address:381 OLD FALMOUTH RD, MARSTONS MILLS MA 026481555 Alt.us Tel. o.::
Alt.*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Tel.No.:
OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But
signature below,I hereby waive this requirement.I am the(check one)) 0 owner ❑ owner's agent.Owner/Agent
Signature Telephone No.
I PERMIT FEE:$75.00 I
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