Electrical Permit Commonwealth,o/Massachusetts Official Use Only
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.1— 1Jepartment of,}ire Services Permit No.
_°!=� °r Occupancy and Fee Checked 35
>.,.�`�,,.�' BOARD OF FIRE PREVENTION RE6ULAiflON'�O7[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIl' T'`PFbRM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 7 C R 12.00
(PLEASE PRINT IN INK OR TYPE LL INFORt�� TJ;pN) Date: / 7 D
City or Town of: �� �// To the Inspecto of ires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described w.
Location(Street&Number) " ( O7 &Ur n/W�`/
Owner or Tenant 76040 Telephone No. l�J
Owner's Address .�
_•
40,
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
I; � Ez�"tAng Service Amps / Volts Overhead
❑ Undgrd❑ No.of Meters
N INei 1'Service Amps / Volts ❑' cz jp Overhead Undgrd 0 No.of Meters
i
�, umber of Feeders and Ampacity
I II n,P j'' Lr' NX og�a ��
tion and Nature of Proposed Electrical Work: � 5ire (5
LI 0 1, Im ), Completion of thefollowin table maybe 'v waived by the Inspector of Wires.
jl 4 No.of Recessed Luminaires No.of Ceil:Sus No.of Total
—
p.(Paddle)Fans Transformers KVA
4V4).of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- No.of Emergency Lighting
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. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump I Number l 1 Tons I KW No.of Self-Contained
Totals: t Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Water No.of Devices or Equivalent
KW No.of No.of Data Wiring:
Heaters Signs Ballasts
No.of Devices or Equivalent
N.
`�
(' OTHER No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
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.)
,.:95 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 ❑ (Specify)
I certify, under th and a fries o
p f perjury,that the information on this application is true and complete.
FIRM NAME: e7/4 t /e lcl,a LIC.NO.: ‘.31,Sa�
Licensee: Signature G; �"�
(If applicable, ter�"eQxTem�pt' n the license nu er.fi�n�1. � LIC. NO.:
'Address:
�a7 >� t0 0 �7 Bus.Tel.No.:ID
g ploy
*Per M.G.L. c. 147, s. 57-61,security work requires Department of Public afety"S"License: Alt.Tel N No.
OWNER'S INSURANCE Lic.
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 ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $