HomeMy WebLinkAboutElectrical Permit ConimonwealLh o/Madsach anti! Official Use Only
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, � cc77 Permit No. ((} ct q Q
e� cX eParEmenE o`.}ire Services
zit Occupancy and Fee Checked yS-06
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-=`"_'-O, BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07]
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kT APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
r— —.� EASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �A I,0+� c�`-� City or Town of: a�t'r,a.,� To the Inspector of Wires:
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f°'`, , c� I By his application the undersigned ives notice of his or her intention to perform the electrical work described below.
c� 'Lo ation(Street&Number) 355 (mA.}- -LS Iu„tl ' 0c,J
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ner or Tenant p...N AU fn j c-o 22. Telephone No. 'j6X 5ya .'?,tea
ner's Address ,r Go IB x
Lu his permit in conjunction with a building permit? Yes KNo ❑ • (Check Appropriate Box)
pose of Buildingt\kt Utility Authorization No.
sting Service Amps / Volts Overhead 0 Undgrd 0 No.of Meters
New Service Amps / Volts Overhead 0 Undgrd ❑ No.of Meters
Number of Feeders and Ampacity 11
Location and Nature of Proposed Electrical Work: igYitc... NPv.i Se -, ,r 0 f- A /V iae.0 f c,..,%-•.--Li
Completion of the followin&table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TfTotal
Trr anan KVAsformers KVA
No.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
Total Initiating Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers
Totals: Detection/Alerting Devices
Q No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
kt . ..1 No.of Devices or Equivalent
No.of Water No.of No.of
1 Heaters KWt .:
Data Wiring:
Ballasts No.of Devices or Equivalent
Signs
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: 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 ^•--"
ndersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. 4-.-1
C CK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Z.ih c(-c, 12 r0
I certify, under the pains and pen lties of perju ,that the information on this application i true and complete. "'`'
FIRM NAME: EiC J icCf Set Jo S S}ew,.S LIC.NO.:
o Licensee: °' .7
p � D ignature LIC.NO.:
(If applicable,enter "exem t"in the lice se n tuber line. Bus.Tel.No.: JG Yid >� S P
N Address: I L.Lr� i$}- Sa���i�C r��t� 3 Alt.Tel.No.: Sot 567 Of
` *Per M.G.L.c. 147,s. 57-61,security work requires Department of Public Safety—§"License: Lic.No. SSCn n(Aap']
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 ❑owner's agent.
Owner/Agent
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Signature Telephone No. PERMIT FEE: $