HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work co he performed in accordance with the Massachusetts Electrical Code, (MEC),527 CMR 12.00
(OFFICE USE ONLY) 1
gl TOWN OF ` N-. r0 UT 1 Q By
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(PLEASE PRINT IN INK OR TYPE ALL IN, FO MAY 2 5 20 0,i te: °° O6
To the Inspector of Wires: By this application the undersigned gives notice of his or h- "nth: f on . perform the electrical
work described below. - HEALTH DEPT. t
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Location(Street&Number)r O� i � �W /0
Owner or Tenant JAM G r E4 0 W Telep .nee o.
Owner's Address
Is this permit in conjunction with a building permit? 1 Yes No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps I Volts OverheadE Undgrd 0 No. of Meters
New Service Amps / Volts OverheadlJ Undgrd 0 No. of Meters
Number of Feeders and Ampacity Location and Nature of Proposed electrical Work:1N`&0 53e 51$
Completion of the following table may be waived by the Inspector of Wire.
No.of Total
No. of Recessed Fixtures . No. of Ceil. Susp.(Paddle)Fans Transformers KVA
NtiNo. of Lighting Outlets No. of Hot Tubs Generators KVA
Above In- No.of Emergency Lighting
No. of Lighting Fixtures Swimming Pool grnd. grnd. Battery Units
\q No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones
No.of Detection and
�� No. of Switches No.of Gas Burners Initiating Devices
4" No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices
Heat PumpNo. of Self-Contained
No. of Waste Disposers Total : i-Number Tons KW Detection/Alerting Devices
Municipal
No. of Dishwashers Space/Area Heating KW Local Connection Other
No.ofDryers HeatingAppliances KW Secutity Systems:
PP No.of Devices or Equipvalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No. H dromassa a Bathtubs No. of Motors Total HP Telecommunications Wiring:
y g No.of Devices or Equivalent
Attach additional detail if desired, or as required by the Inspector of Wires
INSURANCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may be issued 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.
HECK ONE: INSURANCE BOND Q OTHER( (Specify:) .sowve f / o7
(Expiration ate)
< Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
SLI certify, under pains f pe ry e n rmation on this application is true and comple ,. /� /'
FIRM NAME: /OW( � L�%��1'�[� 1y j LIC. NO. ��J/SOc
icensee: Signature yt,�C LIC. NO.
(If applica e, titer"exem t" in the j'ce se1}�ber line) Bus. Tel. No.: L1
Address- i 1D7 f rlc'-(I �7� Alt. Tel. No.:
OWNER'S INSURANt�E AIVER: 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 In owner's agent.Q
Owner/Agent
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