BLDE-22-000521 Commonwealth of Official Use Only
.LTA.
Massachusetts Permit No. BLDE-22-000521
" 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) Date•7/28/2021
City or Town of: YARMOUTH To the 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) 79 STATION AVE
Owner or Tenant Shawn Bent Telephone No.
Owner's Address 79 STATION AVE, SOUTH YARMOUTH, MA 02664 6
Is this permit in conjunction with a building permit? Yes ElNo 0 ( 1
Purpose of Building Utility Authorization ' - ((
Existing Service 100 Amps Volts Overhead 0 Undgrd
New Service 100 Amps Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Upgrade service.
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 g boved. ❑ grnd ❑ No.of Emergency Lighting
rn 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
Tons
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 0 Municipal 0 Other:
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of Devices or Equivalent
Heaters KW No.of No.of Ballasts Data Wiring:
Signs No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
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: 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 (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Jeffrey T Foss
Licensee: Jeffrey T Foss Signature LIC.NO.: 36938
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address:33 SULLIVAN RD,W YARMOUTH MA 026733543 Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License:
OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law.But my
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: $50.00 I
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ram . . , Permit No. O SZl
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I c" : � •PRAT IN INK OR TYPEA.L,L�o accordance
�Electrical Code �`i!"1L WORK
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Lu cot w or Town of: 1� QZ M Date:
(i '''` app
lication the p ffi�, ,.6ce of his or To the In.ve or of _
Ur! r .='n(St eet&Number) I� . , per n u.ion�p p. I�OlIFI st��,��.7
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cr L� T or Tenant Arlir4r i/ A e . I %,4 A below_
r s Address �i=!IN
.r Te hone No. — ,�-OM
Is this penult in conjunction
with Purpose of DtulttrAe a bat�rhag per, Yes ❑ No ►� (Check Appropriate Saar
Service/'0Q Amps ! / Ut ■ orization No. I 0
Existing �� -- vot s
ew •� Amps ( Ovet3tead IIndgrd❑ No.of IMeE�
Number.: F --- vol3ts Overhead II .
�der s and Ampacity / 51 Adgrd❑ No,o€Meters
Location an, Nature Of Pro }} • , ////��/J•/�'�� (/'']
/L/Y A ��° ACC' ! ,Ji jjJ�"1� �1, . i. - 4-
a.of Recessed ..," ..., a the f 4 A,_, . d A '®lam
Luminaires No.of ',table .,,.be '��,r
No.ofiaaire OutletC. Z.-SitsP-(Paddle)Fans . of T �(d(y
No.of Hot Tubs eoeratTransforraers KVA
KVA
No.of: os.of Luminaires
Swimming Pool Above
❑ C° m c9 are: .,,,.
Outlets ❑ ; ,,_ Units
No,of Oil Burners
No,of Switches i; : -- •;aALARMS No.of Zones
No.of Gas Burners i`e.of,�i-..;, , and
No.of :,i.: ■i,a Devkes
No.of Air Cond. otal
No.of
Disposers Pump ,inner onnsoss T.;. Na of Alerting Devices
Na.of DishwashersTotals. 1"0.o = aa=<
SpacelArea Beating KW- aatAt Devices
No.of Dryers
Heating Appliances ,
Local = 0 oche
� + 'o.of 'star _ , Connection
xa„ :*-
$eaters L" , o.of o.of No.of r or :. ,• t
Signs Ballasts Data
No.of Devices
r No.Hydromassage Bathtdbsof Devices or trivalentNo.of Motors Total HP elecommufications „
No.of Devices or .,uiv
alent
-
i Valle of E Work: — Attach addukr (derail fd or¢r •
Wort;to Stan .f Inspections tofeu required by mtmicipal policy.)
r equired by the Inspector o
— INSURANCE be requested in accordance with MEC Rule 10,and the licensesE: Unless waived by the owner,no permit for the performance elm.
psi provides proof of liability insurance inc ludirz p ice of electrical work
l�comes that such coverage is in l;"completed operatioA"cov sutislrttiai �issue unless
force,and ethe 'm its
��INSURANCE ),f BOND 0 OTHER 0 �p�proof of same m the 'mill—�,,g Q lit.
Z.' . �NAME: and.. . :. of that information an this���� C 'n IS trite and complete:
Co ���r
Addale\.....7 Licensem e �� "ura
Suture /1� ue.NO• 8v
r
i ,I / -� r/�j�/ , Lit.NO.:
Per NLG_L c. ge 47,s.57 i,s , ry work 'I3 : i Trap S l ` :us.Tel.No.: 1._=M yvte
l 'ONCE WAIVER I am aware eP, •• ant ofpublic S. ••5"Li--�. • Alt Tel.No.: IRdi,Q,/ .-Y awsignaturebelow,i h ttthe Lrcensee does nor have tine liab Lin No.
`1 Signature
ant bj waive this requiremeot I am the(check oneinsurance coverage
Telephone No_ wner ° �s
PRRMt7->i�P. a 'I