HomeMy WebLinkAboutBLDE-22-003024 Commonwealth a////addachersettd Official Use Only
► WOW? c� Permit No. 2 /d
tI 2)_ epartment o/.7 ire Serviced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07] (leave blank)
Q ���_ ,- ;
' '' PPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
i o v � All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
W-€ 1.1 ) i 9/2j
P ASE PRINT IN INK OR TYP ALL INFORMATION) Date:
i � City or Town of: //""
(��T t`i' Mk To the Inspector of Wires.
:i 13y! his application the undersigned gives notice of his or her intention to perform the electrical work described below.
i,: ' 2 iolttation(Street&Number) Q7 CAP L oTI'/ goP 1 !7 oll LJ
ir-�
u-._ . °AJwfner or Tenant ION A Do scyv Lu Itf teelizA Telephone No.
mmi
-- • - ner's Address
Is this permit in conjunction with a building permit? Yes n No P (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead Undgrd E No.of Meters
New Service Amps / Volts Overhead F, Undgrd E No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: IN 6 h o ter',7 Coo C
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
No.of Luminaires Swimming Pool ❑ yQ
In- .n/No.of Emergency Lighting
grnAboved. 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. Tons No.of Alerting Devices
Heat Pump Number Tons KWNo.of Self-Contained
No.of Waste Disposers
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 nevices or Equivalent
Heaters KWN°•of Data Wiring:
Signs 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:
(When required by municipal policy.)
Work to Start: U /23/, 921 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 ❑ BOND ❑ OTHER ❑ (Specify)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME:
Licensee: LIC. NO.:
��5( c�"N'f! p4 5tt[!/�- Signature___ -- —`-----
2.10
(Ifapplicable, t "exempt"in the license n bet lime.) LIC.NO.:
Address: �T3 Bus.Tel.No.: y
*Per M.G.L. c 147,s 57 61,security work requires Department of Public Safety"S"License: Alt
Licl No. Z 1
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)❑owner E]owner's a•ent.
Owner/Agent
Signature _ Telephone No.
p PERMIT FEE: $