HomeMy WebLinkAboutElectrical Permit APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, (MEC), 527 CMR 12.00
; '.t 44 _, . _ _:_ , (OFFICE USE ONLY) (Rev.9/05)
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'_) TOWN OF ; '` OOTH By
YArTACMEESE 3 6
® G, ��� Fee: $
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. . :: �� PERMIT NO. 67'
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PLEASE PRINT IN INK OR`TYPEAZEIWYORWION) Date: . 6 ift /d7
'0 the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical
iork described below. `�
.ocation(Street& Number) i Ci- 11e1 Pga
)wrier or Tenant (L)M- k _ ?Ir kf Telephone No.
)wner's Address "...I
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s this permit in conjunction with a building permit? Yes allo (Check A•.ro• 'al : A )
'urpose of Building Utility Authorization N./
existing Service ibb Amps w-6 /aK) Volts Overheads Undgrd[73 No. of Meters
vew Service Amps / Volts OverheadP Undgrd 71 No. of Meters
umber of Feeders and Ampacity ?v—COD 4,
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WI (
Location and Nature of Proposed electrical Work: t re T _1G 420 Wl„IVQ `o
Completion of the following table may be waived by the Inspector of Wires
No.of Total `
---,No.of Recessed Luminaires No. of Ceil.-Susp.(Paddle)_Fans ,Transformers KVA
No.of Luminaire Outlets No. of Hot Tubs Generators KVA
Above In- 'No. of Emergency Lighting
No.of Luminaires Swimming_Pool gzrnd. old. Battery Units
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
Total
No. of Ranges No. of Air Cond. Tons No. of Alerting Devices
No.of Waste Disposers Heat o a[ . ' Number Tons `_KW No. of Self Contained
_ 1 Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local 13 Munieipal Connection 71 Other
Security Systems:*
No. of Dryers Heating Appliances KW No.of Devices or Equivalent
No.of Water No. of No. of Data Wirino:
Heaters KW Signs Ballasts No.of Devices or Equivalent
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.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may be issued unless the licensee provides
proot 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:)
(Expiration Date)
Estimated Value qf lectrical Work: (When required by municipal policy.)
Work to Start: / t7� Inspections to be requested in accordance with MEC Rule 10, and upon completion.
l certify, under iii atns Aryl penal i s o per' ry, that the information this application is true and complete
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'-il.RM NA 1KUS e LIC. NO. r'b
ensee: Signature L1C. NO.
If applicabl, enter "exempt" in the license number line.) Bus. Tel. No.: $$�(2,n
lddress: K aaSi 5tV1nIXOiCa Alt. Tel. No.:
Security System Contractor License required for this work;if applicable,enter the license number here:
IWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature
Blow. I hereby waive this requirement. I am the (check one)owner ❑ owner's agent.CI