HomeMy WebLinkAboutBLDE-21-001799 Commons/4mA el Massacluusalld Official Use Only
#a t c� Permit No. - 1n99
, �' 2epariine cc77nf of iris Serviced
C• i_t BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07]
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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) Date: a/S'r��,V
City or Town of: Vh n.,,-,,, I. To the In�dctor o Wires:
P .�
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 4/0 gs ,Ns ep,,,r.f'/ R,'
Owner or Tenant �/I2„-,e„7-iy ?o l fCR' l2 o - Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes g No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No. )3 4//7o) _
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead[r Undgrd ❑ No.of Meters S
Number of Feeders and Ampacity S"'t X A- 7, .C w r
Location and Nature of Proposed Electrical Work: ,ti
citA,p,d4.4."( C/A,A/kevki ... ,2 44,
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 Lightmg
No.of Luminaires Swimming Pool 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 No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER
.S7f to Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of lec 'cal Work: 19) 00 0. (When required by municipal policy.)
Work to Start: u5/.v Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C RAGE: 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 der BOND 0 OTHER 0 (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: LIC.NO.:
Licensee: a()/-f N/ 43,"/( Signature lif LIC.NO.: ,I o3 c y
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.•
Address: 'S J.1,1'lndn-/) , /% hva ✓.t ✓'/ O lire t Alt.Tel.No.: 6.�'"
*Per M.G.L.c. 147,s. 57-61,security work requires Impartment of Public Safety"S"License: Lic.No. / ' -
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)0 owner 0 owner's agent.
Owner/Agent I PFRINTT FF.F.. w../.."
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