HomeMy WebLinkAboutBLDE-21-003501 stow�era!�of/
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Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leave m)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All walk to be performed in acootdimce with the Massachusetts Electrical Code OAK).Sp CMR 12.00
,,i) (PLEASE PRINT ININKOR 7nE ALL INFORMATION) Date: I . 1 i A-0
City or Town of: N G C MO'tk1') To the Inspector of Wires:
By this application the undersigned gins notice of his or her intention to perform the electrical work described below.
v Location(Street&Number) 1 `4 t )ef Ct) LA n.e-.-•--`
Owner or Tenant in/ r►ci J u r+el Telephone No. 111-3 5 401/8
`� Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
• Purpose of Bidding Utility Authorization No.
•, t Existing Service Amps / Volts Overhead❑ Undgrd 0 No.of Meters
New MON Amps / Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ably ..
-'''<i Location and Nature of Proposed Electrical Work: `)I re_,n 6,0-'(i/rn 4 Cr—.....--
,
Completion& fo� ►be bY of
a «ai
e No.of Re eased Lunges Na of Cdi.-4usp.(Paddle)F Transformers IEVA
'mot No.of Luminaire Outlets No.of Rot Tubs Generators KVA
` Above In-
Swimming uric.or ffi•tergauhy"WI"
No.of Lsurndres S Pod ❑ I nnd ❑ Belay Units
..c No.of Receptacle Outlets No.of 011l Burners FIRE ALARMS No.of Zones
Na of SwitchesNo.of Gas Bunters
No.of Detection and
e.
hddatine Devices
I1 No.of Runes No.of Air Cond. Total No.of Alertlng Devises
No.of Waste Disposers >BiewsT> p-. Number Totes j 1 W NaD I
Dodos 1
No.of Dishwashers Space/Area Heating KW of SeliCeiataimed
j !Load❑ a Other
$t�gA Kw :_
No.of Dryma Na of�or Univalent
No.of Water �hlo.of No.
No. Devices or t
of Data Wiring:
Heaters KW sip
No.Fiydrrema sage Bathtubs No. Motors Total HP T Na of Devices or
OTHER:
Attach add Oral detail rdesired or as required by the Impactor of Wires.
Estimated Value of Electrical Work: (When requited 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 0 BOND 0 OTHER information on skis application 0 (Specify:) is trueIcam,as der the pains and penalties ofper)nry. the and tomnplataFIRM1. LIC.NO.:
' UCVIkk i �� LIG NO cl ctB t£
(U� Alt enter.. lim�n/s� lit 0/�s BULL Tel.NNat 7 7 -3bi?-047
Address: of.Public Safety"S"License: Lic.No.
*Per M.G.L.c. 147,s.57-6I,severity work ' insurance coverage fly
OWNER'S INSURANCE WAIVER: I am swan that the Licensee does not have the liability
required by law. By my signature below,I herby waive this requirement I am the(check one)❑owner ❑owners agent i
Ownm/Ag Tine Ns. I PERMIT FEE'5